MEDICARE: ABRAHAM'S MARK COMPREHENSIVE WELLNESS CENTER, SC

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	207Q00000X	Family Medicine Physician
2	261QP2300X	Primary Care Clinic/Center	036096686	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
6	DD6694	OTHER	IL	RAILRAOD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1634166	OTHER	IL	BC/BS
2	7455146	OTHER	IL	CIGNA
3	7779286	OTHER	IL	AETNA PPO
4	0061621	OTHER	IL	TRICARE
5	3474878	OTHER	IL	AETNA HMO

General Provider Information

NPI Number	:	1104857341
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ABRAHAM'S MARK COMPREHENSIVE WELLNESS CENTER, SC

Provider Business Mailing Address
First Line	:	PO BOX 13677
Second Line	:
City	:	BELFAST
State	:	ME
Zip	:	04915-4027
Country	:	US
Telephone Number	:	773-667-0768
Fax Number	:	773-667-5529

Provider Business Practice Location Address
First Line	:	9500 S DORCHESTER AVE
Second Line	:	STE 100
City	:	CHICAGO
State	:	IL
Zip	:	60628-1700
Country	:	US
Telephone Number	:	773-667-0768
Fax Number	:	773-667-5529

Authorized Official
Title or Position	:	OWNER
Name	:	DR. NICOLE D. KING
Credential	:	MD
Telephone Number	:	773-667-0768

Provider Enumeration Date	:	07/05/2006
Last Update Date	:	12/03/2020

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