Healthcare Provider Details

I. General information

NPI: 1922141084
Provider Name (Legal Business Name): IDHS CHICAGO READ MHC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 N OAK PARK AVE
CHICAGO IL
60634-1417
US

IV. Provider business mailing address

4200 N OAK PARK AVE
CHICAGO IL
60634-1417
US

V. Phone/Fax

Practice location:
  • Phone: 773-794-3733
  • Fax: 773-794-4046
Mailing address:
  • Phone: 773-794-3733
  • Fax: 773-794-4046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number
License Number StateIL

VIII. Authorized Official

Name: ANGIE TANSOR
Title or Position: RO1
Credential:
Phone: 773-794-3733