Provider Demographics
| NPI: | 1023286770 |
|---|---|
| Name: | NEW AGE SERVICES CORPORATION |
| Entity type: | Organization |
| Organization Name: | NEW AGE SERVICES CORPORATION |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | PATIENT REVENUE COORDINATOR |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | ULYSSES |
| Authorized Official - Middle Name: | JEROME |
| Authorized Official - Last Name: | JEFFERSON |
| Authorized Official - Suffix: | JR |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 773-542-1150 |
| Mailing Address - Street 1: | 1330 SOUTH KOSTNER AVE. |
| Mailing Address - Street 2: | |
| Mailing Address - City: | CHICAGO |
| Mailing Address - State: | IL |
| Mailing Address - Zip Code: | 60623 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 773-542-1150 |
| Mailing Address - Fax: | 773-542-1175 |
| Practice Address - Street 1: | 1330 SOUTH KOSTNER AVE. |
| Practice Address - Street 2: | |
| Practice Address - City: | CHICAGO |
| Practice Address - State: | IL |
| Practice Address - Zip Code: | 60623 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 773-542-1150 |
| Practice Address - Fax: | 773-542-1175 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2008-02-15 |
| Last Update Date: | 2022-12-20 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 101YA0400X, 101YM0800X, 101YP2500X, 103T00000X, 104100000X, 1041C0700X, 207QA0401X, 2084A0401X, 261QM2800X | ||
| IL | A-0579-0001-A | 251S00000X, 276400000X |
| IL | 16008 | 261QM0801X |
| IL | A-0579-001A | 261QR0405X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 261QM2800X | Ambulatory Health Care Facilities | Clinic/Center | Methadone | |
| No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
| No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health | Group - Multi-Specialty |
| No | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional | Group - Multi-Specialty |
| No | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Multi-Specialty | |
| No | 104100000X | Behavioral Health & Social Service Providers | Social Worker | Group - Multi-Specialty | |
| No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
| No | 207QA0401X | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine | Group - Multi-Specialty |
| No | 2084A0401X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine | Group - Multi-Specialty |
| No | 251S00000X | Agencies | Community/Behavioral Health | Group - Multi-Specialty | |
| No | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | Group - Multi-Specialty |
| No | 261QR0405X | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | Group - Multi-Specialty |
| No | 276400000X | Hospital Units | Rehabilitation, Substance Use Disorder Unit |
