MEDICARE: ALLIANCE HEALTH CARE MANAGENENT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	1119430	IL

General Provider Information

NPI Number	:	1437396082
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALLIANCE HEALTH CARE MANAGENENT

Provider Business Mailing Address
First Line	:	1304 W 77TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60620-3730
Country	:	US
Telephone Number	:	773-994-9631
Fax Number	:	773-783-6058

Provider Business Practice Location Address
First Line	:	1304 W 77TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60620-3730
Country	:	US
Telephone Number	:	773-994-9631
Fax Number	:	773-783-6058

Authorized Official
Title or Position	:	MANAGER
Name	:	WILNESSA MIMS
Credential	:
Telephone Number	:	773-619-9932

Provider Enumeration Date	:	01/18/2009
Last Update Date	:	01/18/2009

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