1093721219 NPI number — WOODSON CENTER FOR ADULT HEALTHCARE SC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093721219 NPI number — WOODSON CENTER FOR ADULT HEALTHCARE SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WOODSON CENTER FOR ADULT HEALTHCARE SC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093721219
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1097
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEDFORD PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60499-1097
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-709-9200
Provider Business Mailing Address Fax Number:
708-756-0348

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
316 DIXIE HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO HEIGHTS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60411-1770
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-709-9200
Provider Business Practice Location Address Fax Number:
708-756-0348
Provider Enumeration Date:
07/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCROY
Authorized Official First Name:
LYNNETTE
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING COORDINATOR
Authorized Official Telephone Number:
773-767-3822

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  036076317 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036076317 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01626967 . This is a "BCBS PROVIDER #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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