Provider Demographics
NPI:1164562609
Name:WELLSPRING CLINICAL ASSOCIATES, INC.
Entity Type:Organization
Organization Name:WELLSPRING CLINICAL ASSOCIATES, INC.
Other - Org Name:INTEGRATED HEALTHCARE SOLUTIONS INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:LEO
Authorized Official - Last Name:DIMATTEO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-541-8930
Mailing Address - Street 1:5950 LINCOLN AVE
Mailing Address - Street 2:UNIT W
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-3388
Mailing Address - Country:US
Mailing Address - Phone:630-541-8930
Mailing Address - Fax:630-541-8940
Practice Address - Street 1:5950 LINCOLN AVE
Practice Address - Street 2:UNIT W
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-3388
Practice Address - Country:US
Practice Address - Phone:630-541-8930
Practice Address - Fax:630-541-8940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
022-32842OtherBC/BS
02227624OtherBLUE CROSS BLUE SHIELD
IL02232842OtherBLUE CROSS BLUE SHIELD