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DSH140206J Humboldt Park Health (Active)
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Main Details
Name
Humboldt Park Health
Subdivision Name
Primary Care Practice
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH140206J
Medicare Provider Number
140206
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
1/13/2016
Participating Start Date
4/1/2016
Participating Approval Date
2/19/2016
Last Recertification Date
9/5/2024
Contacts
Authorizing Official
Humboldt Park Health
Kenneth Coe, Chief Financial Officer
(773) 292-8200 Ext: 8208
Primary Contact
Humboldt Park Health
Ravina Gandhakwala, Director of Pharmacy
(773) 292-8200 Ext: 7380
Addresses
Street Address
1044N MOZART ST 100
CHICAGO, IL 60622-2792
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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June 2025
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