Healthcare Provider Details

I. General information

NPI: 1841356516
Provider Name (Legal Business Name): HARRISON SQUARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 12/23/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 S WOLCOTT AVE, SUITE 605
CHICAGO IL
60612
US

IV. Provider business mailing address

15900 SOUTH CICERO AVE.
OAK FOREST IL
60452-4006
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-4649
  • Fax: 312-864-9763
Mailing address:
  • Phone: 708-633-3486
  • Fax: 708-633-3449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SCOTT ANDRLE
Title or Position: DIRECTOR OF MANAGED CARE OPERATIONS
Credential:
Phone: 312-864-4649