Provider Demographics
NPI:1407002108
Name:SWEDISH COVENANT MANAGEMENT SERVICES, INC.
Entity Type:Organization
Organization Name:SWEDISH COVENANT MANAGEMENT SERVICES, INC.
Other - Org Name:COMPREHENSIVE WELLNESS CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT,OPERATION/CFO
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:KRUGEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-878-8200
Mailing Address - Street 1:5019 N MOZART ST
Mailing Address - Street 2:ATTN: SOULTANA AMAXOPOULOS
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3615
Mailing Address - Country:US
Mailing Address - Phone:773-293-3223
Mailing Address - Fax:
Practice Address - Street 1:2825 N HALSTED ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5105
Practice Address - Country:US
Practice Address - Phone:773-549-8900
Practice Address - Fax:773-549-8511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-13
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036117858207Q00000X
IL036-086740207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========6067402Medicaid
IL=========6067402Medicaid