Provider Demographics
NPI:1891944484
Name:HEALTH PROVIDERS
Entity Type:Organization
Organization Name:HEALTH PROVIDERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:O
Authorized Official - Last Name:ROPER
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MS
Authorized Official - Phone:312-421-3434
Mailing Address - Street 1:1507 W POLK ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-3120
Mailing Address - Country:US
Mailing Address - Phone:312-421-3434
Mailing Address - Fax:312-421-5237
Practice Address - Street 1:19330 S COTTAGE GROVE AVE
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:IL
Practice Address - Zip Code:60425-1834
Practice Address - Country:US
Practice Address - Phone:708-758-6200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-18
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036055359102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
933860Medicare PIN