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General NPI Number Information
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NPI Number | 1558595272
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Entity Type | Organization
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Legal Business Name | 22ND CENTURY HEALTHCARE, P.C.
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Dates
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Enumeration Date | 05/09/2009
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Last Update Date | 05/09/2009
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Provider Practice Location Address
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Address Line | 875 N MICHIGAN AVE SUITE 3100
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City | CHICAGO
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State | IL
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Zip | 60611-1803
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Country | US
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Telephone | 773-362-5461
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Fax |
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Provider Business Mailing Address
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Address Line | 3712 N BROADWAY ST SUITE 629
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City | CHICAGO
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State | IL
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Zip | 60613-4235
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | BO HEADLAM
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Credential | MD
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Telephone | 773-362-5461
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2081P2900X
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Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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