Provider Demographics
NPI:1295727469
Name:MOBILE WOUNDCARE CONSULTANTS
Entity type:Organization
Organization Name:MOBILE WOUNDCARE CONSULTANTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:847-337-1397
Mailing Address - Street 1:PO BOX 405
Mailing Address - Street 2:
Mailing Address - City:MT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-0405
Mailing Address - Country:US
Mailing Address - Phone:847-337-1397
Mailing Address - Fax:866-840-2110
Practice Address - Street 1:514 TEELA LN
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-1230
Practice Address - Country:US
Practice Address - Phone:847-337-1397
Practice Address - Fax:866-840-2110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL332520251001Medicaid
IL326644911001Medicaid
ILP75319Medicare UPIN
IL209632Medicare ID - Type UnspecifiedPRACTICE ID
IL326644911001Medicaid