Provider Demographics
NPI:1467655894
Name:ILLINOIS INSTITUTE FOR INTEGRATIVE MENTAL HEALTH LTD
Entity Type:Organization
Organization Name:ILLINOIS INSTITUTE FOR INTEGRATIVE MENTAL HEALTH LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ELDIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DZUDZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-342-0312
Mailing Address - Street 1:101 W SUPERIOR ST APT 504
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-7655
Mailing Address - Country:US
Mailing Address - Phone:312-342-0312
Mailing Address - Fax:
Practice Address - Street 1:4770 N LINCOLN AVE STE 7
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-1056
Practice Address - Country:US
Practice Address - Phone:312-342-0312
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361005142084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK40585Medicare UPIN
IL706360Medicare PIN