Provider Demographics
NPI:1093721219
Name:WOODSON CENTER FOR ADULT HEALTHCARE SC
Entity Type:Organization
Organization Name:WOODSON CENTER FOR ADULT HEALTHCARE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LYNNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCROY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-767-3822
Mailing Address - Street 1:PO BOX 1097
Mailing Address - Street 2:
Mailing Address - City:BEDFORD PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60499-1097
Mailing Address - Country:US
Mailing Address - Phone:708-709-9200
Mailing Address - Fax:708-756-0348
Practice Address - Street 1:316 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-1770
Practice Address - Country:US
Practice Address - Phone:708-709-9200
Practice Address - Fax:708-756-0348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036076317174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036076317Medicaid
IL01626967OtherBCBS PROVIDER #
IL609070Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
ILE18814Medicare UPIN