Healthcare Provider Details

I. General information

NPI: 1669730107
Provider Name (Legal Business Name): QUN WU MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2012
Last Update Date: 05/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 W 103RD ST 100
CHICAGO IL
60643-2357
US

IV. Provider business mailing address

855 W 103RD ST 100
CHICAGO IL
60643-2357
US

V. Phone/Fax

Practice location:
  • Phone: 773-239-9600
  • Fax: 773-239-9601
Mailing address:
  • Phone: 773-239-9600
  • Fax: 773-239-9601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number036125727
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number036125727
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number036125727
License Number StateIL

VIII. Authorized Official

Name: MS. ANGELA J RATCLIFFE
Title or Position: CHIEF OPERATIONS OFFICER
Credential:
Phone: 773-239-9600