MEDICARE: 4D HEALTHWARE, LLC

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	171M00000X	Case Manager/Care Coordinator
2	171M00000X	Case Manager/Care Coordinator	036-094623	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	OPTIONAL	OTHER	IL	OPTIONAL OPT OUT

General Provider Information

NPI Number	:	1407333685
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	4D HEALTHWARE, LLC

Provider Business Mailing Address
First Line	:	401 N MICHIGAN AVE STE 1740
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-4742
Country	:	US
Telephone Number	:	224-633-9472
Fax Number	:	630-857-9069

Provider Business Practice Location Address
First Line	:	401 N MICHIGAN AVE STE 1740
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-4742
Country	:	US
Telephone Number	:	224-633-9472
Fax Number	:	630-857-9069

Authorized Official
Title or Position	:	FOUNDER/CEO
Name	:	STAR CUNNINGHAM
Credential	:
Telephone Number	:	847-650-7827

Provider Enumeration Date	:	07/20/2018
Last Update Date	:	06/11/2019

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Directions to “4D HEALTHWARE, LLC ” Practice Location

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