Provider Demographics
NPI:1558595272
Name:22ND CENTURY HEALTHCARE, P.C.
Entity Type:Organization
Organization Name:22ND CENTURY HEALTHCARE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BO
Authorized Official - Middle Name:
Authorized Official - Last Name:HEADLAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-362-5461
Mailing Address - Street 1:3712 N BROADWAY ST
Mailing Address - Street 2:SUITE 629
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-4235
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:875 N MICHIGAN AVE
Practice Address - Street 2:SUITE 3100
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-1803
Practice Address - Country:US
Practice Address - Phone:773-362-5461
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-09
Last Update Date:2009-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty