Healthcare Provider Details

I. General information

NPI: 1568724086
Provider Name (Legal Business Name): ILLINOIS COORDINATED CARE PARTNERSHIP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1359 W WASHINGTON BLVD
CHICAGO IL
60607-1905
US

IV. Provider business mailing address

1359 W WASHINGTON BLVD
CHICAGO IL
60607-1905
US

V. Phone/Fax

Practice location:
  • Phone: 312-554-0600
  • Fax: 312-554-8161
Mailing address:
  • Phone: 312-554-0600
  • Fax: 312-554-8161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number4549088621
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. GEORGE JONES JR.
Title or Position: PRESIDENT
Credential:
Phone: 312-554-0600