MEDICARE: TRANSFORMEDGE, P.C.

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	104100000X	Social Worker
2	103TC0700X	Clinical Psychologist

General Provider Information

NPI Number	:	1528691748
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRANSFORMEDGE, P.C.

Provider Business Mailing Address
First Line	:	PO BOX 2193
Second Line	:
City	:	NORTHBROOK
State	:	IL
Zip	:	60065-2193
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	53 W JACKSON BLVD STE 824
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60604-3487
Country	:	US
Telephone Number	:	312-835-7988
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JOSEPH CHEN
Credential	:
Telephone Number	:	312-835-7988

Provider Enumeration Date	:	02/17/2020
Last Update Date	:	04/13/2020

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