MEDICARE: MR. IVAN CECIL JAMES IV MSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	149027003	IL

General Provider Information

NPI Number	:	1104135029
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. IVAN CECIL JAMES IV MSW

Provider Business Mailing Address
First Line	:	5644 S OAKLEY AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60636-1025
Country	:	US
Telephone Number	:	773-317-4900
Fax Number	:

Provider Business Practice Location Address
First Line	:	8023 S INDIANA AVE
Second Line	:	APT 2
City	:	CHICAGO
State	:	IL
Zip	:	60619-3506
Country	:	US
Telephone Number	:	773-317-4900
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2010
Last Update Date	:	01/23/2026

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