MEDICARE: 219 HEALTH NETWORK INC

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	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1578105490
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	219 HEALTH NETWORK INC

Provider Business Mailing Address
First Line	:	100 W CHICAGO AVE STE F
Second Line	:
City	:	EAST CHICAGO
State	:	IN
Zip	:	46312-3261
Country	:	US
Telephone Number	:	219-703-2583
Fax Number	:

Provider Business Practice Location Address
First Line	:	2001 E COLUMBUS DR
Second Line	:
City	:	EAST CHICAGO
State	:	IN
Zip	:	46312-4109
Country	:	US
Telephone Number	:	219-398-9840
Fax Number	:	219-398-9845

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	WILLIAM CORTES
Credential	:
Telephone Number	:	219-703-2585

Provider Enumeration Date	:	10/11/2019
Last Update Date	:	08/16/2024

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