Provider Demographics
NPI:1871749473
Name:NEAR NORTH HEALTH SERVICE CORPORATION
Entity type:Organization
Organization Name:NEAR NORTH HEALTH SERVICE CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:CUSH
Authorized Official - Middle Name:
Authorized Official - Last Name:MVUDUDU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-337-1073
Mailing Address - Street 1:1276 N CLYBOURN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-2089
Mailing Address - Country:US
Mailing Address - Phone:312-337-1073
Mailing Address - Fax:312-337-7616
Practice Address - Street 1:1276 N CLYBOURN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-2089
Practice Address - Country:US
Practice Address - Phone:312-337-1073
Practice Address - Fax:312-337-7616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-14
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QF0400X
ILA09410001A261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========002Medicaid