Provider Demographics
NPI:1609821164
Name:TRISTATE WELLNESS MGT LLC
Entity Type:Organization
Organization Name:TRISTATE WELLNESS MGT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-646-5738
Mailing Address - Street 1:2826 N TALMAN
Mailing Address - Street 2:UNIT J
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-7828
Mailing Address - Country:US
Mailing Address - Phone:708-646-5738
Mailing Address - Fax:866-587-1485
Practice Address - Street 1:2826 N TALMAN
Practice Address - Street 2:UNIT J
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-7828
Practice Address - Country:US
Practice Address - Phone:708-646-5738
Practice Address - Fax:866-587-1485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL336-008797103TC0700X
IL036093462103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036039387Medicaid
IL036093462Medicaid
ILE572246Medicare UPIN
ILK26727Medicare ID - Type UnspecifiedDR. BENJAMIN MARGOLIS
213378Medicare UPIN
ILH46124Medicare UPIN
IL431830Medicare PIN
IL213378Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
IL036093462Medicaid