MEDICARE: EXCELSIOR MEDICAL CENTER LTD

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	208000000X	Pediatrics Physician		IL

General Provider Information

NPI Number	:	1174709117
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXCELSIOR MEDICAL CENTER LTD

Provider Business Mailing Address
First Line	:	333 E IL ROUTE 83
Second Line	:	SUITE 107
City	:	MUNDELEIN
State	:	IL
Zip	:	60060-4214
Country	:	US
Telephone Number	:	847-566-5556
Fax Number	:	847-566-8886

Provider Business Practice Location Address
First Line	:	333 E IL ROUTE 83
Second Line	:	SUITE 107
City	:	MUNDELEIN
State	:	IL
Zip	:	60060-4214
Country	:	US
Telephone Number	:	847-566-5556
Fax Number	:	847-566-8886

Authorized Official
Title or Position	:	OWNER
Name	:	DR. OLGA ULYANOVA
Credential	:	M.D.
Telephone Number	:	847-566-5556

Provider Enumeration Date	:	01/19/2008
Last Update Date	:	01/19/2008

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