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General NPI Number Information
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NPI Number | 1356717151
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Entity Type | Organization
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Legal Business Name | CHURCHWELL PSYCHIATRY, S.C.
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Dates
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Enumeration Date | 08/15/2015
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Last Update Date | 08/15/2015
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Provider Practice Location Address
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Address Line | 636 CHURCH ST STE 409A
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City | EVANSTON
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State | IL
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Zip | 60201-4580
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Country | US
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Telephone | 312-239-3951
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Fax | 888-835-4696
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Provider Business Mailing Address
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Address Line | 636 CHURCH ST STE 409A
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City | EVANSTON
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State | IL
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Zip | 60201-4580
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Country | US
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Telephone | 312-239-3951
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Fax | 888-835-4696
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MICHAEL THOMAS CHURCHWELL
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Credential | M.D.
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Telephone | 312-239-3951
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | 042620450
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License Number State | IL
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