MEDICARE: ILLINOIS DEPARTMENT OF HUMAN SERVICES

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	283Q00000X	Psychiatric Hospital		IL

General Provider Information

NPI Number	:	1407900343
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ILLINOIS DEPARTMENT OF HUMAN SERVICES

Provider Business Mailing Address
First Line	:	4200 N OAK PARK AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-1417
Country	:	US
Telephone Number	:	773-794-3733
Fax Number	:	773-794-4046

Provider Business Practice Location Address
First Line	:	4200 N OAK PARK AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-1417
Country	:	US
Telephone Number	:	773-794-3733
Fax Number	:	773-794-4046

Authorized Official
Title or Position	:	PATIENT RESOURCE UNIT REP
Name	:	ANGIE C TANSOR
Credential	:
Telephone Number	:	773-794-3733

Provider Enumeration Date	:	01/22/2007
Last Update Date	:	07/21/2022

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Directions to “ILLINOIS DEPARTMENT OF HUMAN SERVICES ” Practice Location

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