MEDICARE: LAVOLL AND EDGER, S.C.

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	036069216	IL

General Provider Information

NPI Number	:	1306932751
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAVOLL AND EDGER, S.C.

Provider Business Mailing Address
First Line	:	3122 N SHERIDAN RD APT B2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-4936
Country	:	US
Telephone Number	:	312-209-1123
Fax Number	:	312-988-9215

Provider Business Practice Location Address
First Line	:	3122 N SHERIDAN RD APT B2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-4936
Country	:	US
Telephone Number	:	312-209-1123
Fax Number	:	312-988-9215

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ROBERT EDGER
Credential	:	MD
Telephone Number	:	312-209-1123

Provider Enumeration Date	:	10/05/2006
Last Update Date	:	07/21/2022

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