Basic Information
| Provider Information | |||||||||
| NPI: | 1912027665 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIAMOND HEADACHE CLINIC LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1460 N HALSTED ST STE 501 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606422615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7733886390 | ||||||||
| FaxNumber: | 3128677101 | ||||||||
| Practice Location | |||||||||
| Address1: | 1460 N HALSTED ST STE 501 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606422615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7733886390 | ||||||||
| FaxNumber: | 3128677101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2007 | ||||||||
| LastUpdateDate: | 12/26/2017 | ||||||||
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| AuthorizedOfficialLastName: | DIAMOND | ||||||||
| AuthorizedOfficialFirstName: | MERLE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7733886390 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1616611 | 01 | IL | BCBS | OTHER |