Healthcare Provider Details

I. General information

NPI: 1922549294
Provider Name (Legal Business Name): COMMUNITY TRIAGE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2017
Last Update Date: 03/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E 115TH ST
CHICAGO IL
60628-5015
US

IV. Provider business mailing address

200 E 115TH ST
CHICAGO IL
60628-5015
US

V. Phone/Fax

Practice location:
  • Phone: 773-291-2500
  • Fax:
Mailing address:
  • Phone: 773-291-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

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