MEDICARE: NORTH MESA STREET MEDICAL CENTER LLC

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	208600000X	Surgery Physician

General Provider Information

NPI Number	:	1144601634
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH MESA STREET MEDICAL CENTER LLC

Provider Business Mailing Address
First Line	:	100 TOWER DR
Second Line	:	232
City	:	BURR RIDGE
State	:	IL
Zip	:	60527-5777
Country	:	US
Telephone Number	:	630-926-3408
Fax Number	:

Provider Business Practice Location Address
First Line	:	4532 N MESA ST
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79912-6102
Country	:	US
Telephone Number	:	630-926-3408
Fax Number	:

Authorized Official
Title or Position	:	VP BUSINESS DEVELOPMENT
Name	:	ANITA SINGH
Credential	:	MA
Telephone Number	:	630-926-3408

Provider Enumeration Date	:	06/10/2015
Last Update Date	:	06/10/2015

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