Provider Demographics
NPI:1588842942
Name:BOBBY E WRIGHT COMPREHENSIVE BEHAVIORAL HEALTH CENTER INC.
Entity Type:Organization
Organization Name:BOBBY E WRIGHT COMPREHENSIVE BEHAVIORAL HEALTH CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:SIMONE
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-722-7900
Mailing Address - Street 1:5002 W MADISON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60644-4127
Mailing Address - Country:US
Mailing Address - Phone:773-722-7900
Mailing Address - Fax:773-722-0644
Practice Address - Street 1:3527 W JACKSON BLVD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60624-3255
Practice Address - Country:US
Practice Address - Phone:773-722-7900
Practice Address - Fax:773-722-0644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL251B00000X, 251S00000X, 320800000X
261QM0801X, 320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========005Medicaid
ILIL7164Medicare PIN