Provider Demographics
NPI:1912027665
Name:DIAMOND HEADACHE CLINIC LTD
Entity Type:Organization
Organization Name:DIAMOND HEADACHE CLINIC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MERLE
Authorized Official - Middle Name:L
Authorized Official - Last Name:DIAMOND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-388-6390
Mailing Address - Street 1:1460 N HALSTED ST STE 501
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-2615
Mailing Address - Country:US
Mailing Address - Phone:773-388-6390
Mailing Address - Fax:312-867-7101
Practice Address - Street 1:1460 N HALSTED ST STE 501
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-2615
Practice Address - Country:US
Practice Address - Phone:773-388-6390
Practice Address - Fax:312-867-7101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2017-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1616611OtherBCBS
IL1616611OtherBCBS