=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124073143
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GLOBAL COMMUNITY MENTAL HEALTH CENTER SE SUB INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2006
-----------------------------------------------------
Last Update Date | 01/06/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3011 183RD ST SUITE # 300
-----------------------------------------------------
City | HOMEWOOD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60430-2804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-720-6609
-----------------------------------------------------
Fax | 708-748-6180
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3011 183RD ST SUITE # 300
-----------------------------------------------------
City | HOMEWOOD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60430-2804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-720-6609
-----------------------------------------------------
Fax | 708-748-6180
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | C.E.O.
-----------------------------------------------------
Name | ANWAR S YAMINI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 708-720-6609
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 036055245
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 036055245
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------