Provider Demographics
NPI:1639542681
Name:MYSI CORPORATION
Entity Type:Organization
Organization Name:MYSI CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:TOLEDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-840-4600
Mailing Address - Street 1:3001 W 111TH ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-2240
Mailing Address - Country:US
Mailing Address - Phone:773-840-4600
Mailing Address - Fax:773-840-4606
Practice Address - Street 1:3001 W 111TH ST
Practice Address - Street 2:SUITE 103
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60655-2240
Practice Address - Country:US
Practice Address - Phone:773-840-4600
Practice Address - Fax:773-840-4606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-12
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL15011251S00000X, 261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL15011Medicaid