Provider Demographics
NPI:1104004621
Name:BOBBY E WRIGHT COMPREHENSIVE BEHAVIORAL HEALTH CENTER INC.
Entity type:Organization
Organization Name:BOBBY E WRIGHT COMPREHENSIVE BEHAVIORAL HEALTH CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BILLING
Authorized Official - Prefix:MS
Authorized Official - First Name:TAKASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCINTOSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-722-7900
Mailing Address - Street 1:5002 W MADISON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60644-4127
Mailing Address - Country:US
Mailing Address - Phone:773-722-7900
Mailing Address - Fax:773-722-0644
Practice Address - Street 1:4133 W MADISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60624-2304
Practice Address - Country:US
Practice Address - Phone:773-722-7900
Practice Address - Fax:773-722-0644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-06
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========007Medicaid
IL7164001Medicare PIN
ILIL7164Medicare PIN
IL=========007Medicaid