=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952957698
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHLAND CARE COORDINATION PARTNERS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2019
-----------------------------------------------------
Last Update Date | 05/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 HOLIDAY PLAZA DR
-----------------------------------------------------
City | MATTESON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60443-2241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-996-4002
-----------------------------------------------------
Fax | 708-898-0142
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 HOLIDAY PLAZA DR
-----------------------------------------------------
City | MATTESON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60443-2241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-996-4002
-----------------------------------------------------
Fax | 708-898-0142
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | TREASURER
-----------------------------------------------------
Name | DR. ANN ASSAM
-----------------------------------------------------
Credential | PHAMD
-----------------------------------------------------
Telephone | 708-567-2053
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 347E00000X
-----------------------------------------------------
Taxonomy Name | Transportation Broker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------