MEDICARE: MR. GEORGE L PAULEY MSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	016-05084	OTHER	IL	BLUE CROSS BLUE SHIELD IL

General Provider Information

NPI Number	:	1043368608
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GEORGE L PAULEY MSW

Provider Business Mailing Address
First Line	:	5415 N SHERIDAN RD
Second Line	:	#4811
City	:	CHICAGO
State	:	IL
Zip	:	60640-1954
Country	:	US
Telephone Number	:	773-784-4566
Fax Number	:

Provider Business Practice Location Address
First Line	:	464 CENTRAL AVE
Second Line	:	#30
City	:	NORTHFIELD
State	:	IL
Zip	:	60093-3040
Country	:	US
Telephone Number	:	847-446-5545
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/08/2007
Last Update Date	:	07/08/2007

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