Provider Demographics
NPI:1316115223
Name:394567 D NORTH
Entity type:Organization
Organization Name:394567 D NORTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REIMBURSEMENT OFFICER I
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:TANSOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-794-3733
Mailing Address - Street 1:4200 NORTH OAK PARK AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-1417
Mailing Address - Country:US
Mailing Address - Phone:773-794-3733
Mailing Address - Fax:773-794-4046
Practice Address - Street 1:4200 NORTH OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-1417
Practice Address - Country:US
Practice Address - Phone:773-794-3733
Practice Address - Fax:773-794-4046
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IL DEPT OF HUMAN SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-13
Last Update Date:2008-06-19
Deactivation Date:2008-06-03
Deactivation Code:
Reactivation Date:2008-06-19
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit