1598840936 NPI number — FAMILY CHILD & ADOLESCENT PSYCHIATRIC SERVICES SC

Table of content: (NPI 1598840936)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598840936 NPI number — FAMILY CHILD & ADOLESCENT PSYCHIATRIC SERVICES SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY CHILD & ADOLESCENT PSYCHIATRIC SERVICES 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:
1598840936
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/11/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
833 W 15TH PL
Provider Second Line Business Mailing Address:
UNIT 815
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60608-1429
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-206-1300
Provider Business Mailing Address Fax Number:
708-206-1399

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 OLD FRANKFORT WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRANKFORT
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60423-1719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-206-1300
Provider Business Practice Location Address Fax Number:
708-206-1399
Provider Enumeration Date:
10/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
AQUINO
Authorized Official First Name:
MILA
Authorized Official Middle Name:
B
Authorized Official Title or Position:
MEDICAL BILLING SERVICE
Authorized Official Telephone Number:
951-282-0060

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  036067468 , 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: 119475 . This is a "COMPSYCH PROVIDER #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036067468 . This is a "LICENSE #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 155000 . This is a "PSYCHEALTH PROVIDER #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 166548 . This is a "HARMONY PROVIDER #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 018896 . This is a "VALUEOPTIONS PROVIDER #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036067468 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3103879 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 31603879 . This is a "BCBS PROVIDER #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 35928 . This is a "AMERICAID PROVIDER #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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