1356563563 NPI number — COMWELL

Table of content: (NPI 1356563563)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356563563 NPI number — COMWELL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMWELL
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:
HUMAN SERVICE CENTER OF SOUTHERN METRO EAST
Provider Other Organization Name Type Code:
4
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:
1356563563
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10257 STATE ROUTE THREE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RED BUD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62278
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-282-6233
Provider Business Mailing Address Fax Number:
618-282-6949

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2517 STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHESTER
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62233-1149
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-826-4547
Provider Business Practice Location Address Fax Number:
618-282-6220
Provider Enumeration Date:
05/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BROWNE
Authorized Official First Name:
KIMBER
Authorized Official Middle Name:
L
Authorized Official Title or Position:
DIRECTOR OF FINANCE
Authorized Official Telephone Number:
618-282-6233

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X , with the licence number:  A-0280-0004-A , 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)





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