Provider Demographics
NPI:1720453947
Name:DR. MENDENHALL
Entity type:Organization
Organization Name:DR. MENDENHALL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR BILLER/ EXEC. ASST.
Authorized Official - Prefix:MS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:331-643-5238
Mailing Address - Street 1:8104 S KINGSTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-1231
Mailing Address - Country:US
Mailing Address - Phone:773-434-6715
Mailing Address - Fax:
Practice Address - Street 1:8104 S KINGSTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-1231
Practice Address - Country:US
Practice Address - Phone:773-434-6715
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-14
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL21415251S00000X
IL180.007149251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health