Healthcare Provider Details

I. General information

NPI: 1437344207
Provider Name (Legal Business Name): RUSH AMBULATORY BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2007
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 W. HARRISON ST.
CHICAGO IL
60612-3706
US

IV. Provider business mailing address

2150 W. HARRISON ST.
CHICAGO IL
60612-3706
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-7320
  • Fax:
Mailing address:
  • Phone: 312-942-7320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code364SP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number StateIL
# 7
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateIL

VIII. Authorized Official

Name: ARTHUR H ROGGOW
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 312-942-7801