Provider Demographics
NPI:1053559898
Name:CHICAGO MENTAL HEALTH DAY PROGRAM AND WELLNESS CLINIC
Entity type:Organization
Organization Name:CHICAGO MENTAL HEALTH DAY PROGRAM AND WELLNESS CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/DIRECTOR OF CLINIC
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:PAPONOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-237-8722
Mailing Address - Street 1:8926 GREENWOOD AVENUE
Mailing Address - Street 2:SUITE 167
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714
Mailing Address - Country:US
Mailing Address - Phone:773-699-8992
Mailing Address - Fax:
Practice Address - Street 1:8926 GREENWOOD
Practice Address - Street 2:SUITE 167
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714
Practice Address - Country:US
Practice Address - Phone:773-699-8992
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHICAGO MENTAL HEALTH DAY PROGRAM AND WELLNESS CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-02
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360919742207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG89996Medicare UPIN
IL1134110448Medicare PIN