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General NPI Number Information
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NPI Number | 1679842470
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Entity Type | Organization
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Legal Business Name | INTEGRACARE
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Dates
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Enumeration Date | 12/22/2011
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Last Update Date | 12/27/2011
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Provider Practice Location Address
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Address Line | 1750 E 87TH ST SUITE 107
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City | CHICAGO
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State | IL
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Zip | 60617-2713
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Country | US
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Telephone | 773-734-3890
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Fax |
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Provider Business Mailing Address
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Address Line | 2731 W POLK ST SUITE 2
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City | CHICAGO
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State | IL
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Zip | 60612-4033
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Country | US
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Telephone | 773-722-7000
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. OTUONYE EZERIBE ONYEWUCHI
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Credential | MD, MPH
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Telephone | 312-550-2586
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 036118945
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License Number State | IL
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