MEDICARE: SIXTEENTH STREET COMMUNITY HEALTH CENTER, 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	261QM0855X	Adolescent and Children Mental Health Clinic/Center
2	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1619612835
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SIXTEENTH STREET COMMUNITY HEALTH CENTER, INC

Provider Business Mailing Address
First Line	:	PO BOX 778789
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60677-0001
Country	:	US
Telephone Number	:	414-672-1353
Fax Number	:	414-672-0191

Provider Business Practice Location Address
First Line	:	920 S 9TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53204-1361
Country	:	US
Telephone Number	:	414-672-1353
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	MARIA CECILIA S TAYLOR
Credential	:
Telephone Number	:	414-897-5407

Provider Enumeration Date	:	05/02/2022
Last Update Date	:	05/02/2022

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