Provider Demographics
NPI:1104857341
Name:ABRAHAM'S MARK COMPREHENSIVE WELLNESS CENTER, SC
Entity Type:Organization
Organization Name:ABRAHAM'S MARK COMPREHENSIVE WELLNESS CENTER, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:D
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-667-0768
Mailing Address - Street 1:PO BOX 13677
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4027
Mailing Address - Country:US
Mailing Address - Phone:773-667-0768
Mailing Address - Fax:773-667-5529
Practice Address - Street 1:9500 S DORCHESTER AVE
Practice Address - Street 2:STE 100
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-1700
Practice Address - Country:US
Practice Address - Phone:773-667-0768
Practice Address - Fax:773-667-5529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
IL036096686261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1634166OtherBC/BS
IL7455146OtherCIGNA
IL7779286OtherAETNA PPO
IL0061621OtherTRICARE
IL3474878OtherAETNA HMO
ILDD6694OtherRAILRAOD MEDICARE
IL1634166OtherBC/BS