MEDICARE: KING I LTD

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	261QM0850X	Adult Mental Health Clinic/Center		IL

General Provider Information

NPI Number	:	1932155066
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KING I LTD

Provider Business Mailing Address
First Line	:	5301 W MADISON ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60644-4040
Country	:	US
Telephone Number	:	773-261-1200
Fax Number	:	773-261-1212

Provider Business Practice Location Address
First Line	:	5301 W MADISON ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60644-4040
Country	:	US
Telephone Number	:	773-261-1200
Fax Number	:	773-261-1212

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GARTRELL DAVE W KING
Credential	:	M.D.
Telephone Number	:	773-261-1200

Provider Enumeration Date	:	05/26/2006
Last Update Date	:	08/22/2020

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