MEDICARE: DR. MARY MARYLAND NP-C, PHD, MSN

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	363L00000X	Nurse Practitioner	209003959	IL

General Provider Information

NPI Number	:	1093740953
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY MARYLAND NP-C, PHD, MSN

Provider Business Mailing Address
First Line	:	420 HOME AVE
Second Line	:
City	:	OAK PARK
State	:	IL
Zip	:	60302-3770
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1900 W TAYLOR ST
Second Line	:	SUITE 172
City	:	CHICAGO
State	:	IL
Zip	:	60612-3742
Country	:	US
Telephone Number	:	312-413-2042
Fax Number	:	312-996-5984

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

Provider Enumeration Date	:	07/11/2006
Last Update Date	:	07/08/2007

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