=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336685494
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 7739956300
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2017
-----------------------------------------------------
Last Update Date | 01/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1029 E 130TH ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60628-6908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-995-6300
-----------------------------------------------------
Fax | 773-995-6192
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1029 E.130TH STREET
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-995-6300
-----------------------------------------------------
Fax | 773-995-6192
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING CODING SPECIALIST
-----------------------------------------------------
Name | MS. MARQUETTA D HALL
-----------------------------------------------------
Credential | CPCS
-----------------------------------------------------
Telephone | 773-995-6300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149018713
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------