Provider Demographics
NPI:1982046355
Name:DUBOIS-DOUGLAS, INC.
Entity Type:Organization
Organization Name:DUBOIS-DOUGLAS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:FUNMI
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINS-MENSAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-295-3146
Mailing Address - Street 1:1016 W JACKSON BLVD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-2914
Mailing Address - Country:US
Mailing Address - Phone:312-288-8640
Mailing Address - Fax:312-243-1516
Practice Address - Street 1:1016 W JACKSON BLVD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-2914
Practice Address - Country:US
Practice Address - Phone:312-288-8640
Practice Address - Fax:312-243-1516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-25
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL12HM519014253Z00000X
ILQMXHPQ0915253Z00000X
IL44CSA00737302R00000X
ILQXIPQ0000096439305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
No305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0802Medicaid
IL0100Medicaid
IL0301Medicaid
IL0302Medicaid
IL0302Medicaid