Provider Demographics
NPI:1407333685
Name:4D HEALTHWARE, LLC
Entity Type:Organization
Organization Name:4D HEALTHWARE, LLC
Other - Org Name:4D HEALTHWARE LLC CLINICAL CONSORTIUM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FOUNDER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:STAR
Authorized Official - Middle Name:
Authorized Official - Last Name:CUNNINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-650-7827
Mailing Address - Street 1:401 N MICHIGAN AVE STE 1740
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4742
Mailing Address - Country:US
Mailing Address - Phone:224-633-9472
Mailing Address - Fax:630-857-9069
Practice Address - Street 1:401 N MICHIGAN AVE STE 1740
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-4742
Practice Address - Country:US
Practice Address - Phone:224-633-9472
Practice Address - Fax:630-857-9069
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:4D HEALTHWARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-07-20
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-094623171M00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILOPTIONALOtherOPTIONAL OPT OUT