Provider Demographics
NPI:1679842470
Name:INTEGRACARE
Entity type:Organization
Organization Name:INTEGRACARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:OTUONYE
Authorized Official - Middle Name:EZERIBE
Authorized Official - Last Name:ONYEWUCHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:312-550-2586
Mailing Address - Street 1:2731 W POLK ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4033
Mailing Address - Country:US
Mailing Address - Phone:773-722-7000
Mailing Address - Fax:
Practice Address - Street 1:1750 E 87TH ST
Practice Address - Street 2:SUITE 107
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-2713
Practice Address - Country:US
Practice Address - Phone:773-734-3890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DOCTORS UNLIMITED SERVICE CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-22
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036118945261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1265739643Medicare UPIN