MEDICARE: CHILD & ADOLESCENT HEALTH ASSOC 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1346230299
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHILD & ADOLESCENT HEALTH ASSOC LTD

Provider Business Mailing Address
First Line	:	PO BOX 189
Second Line	:
City	:	MATTESON
State	:	IL
Zip	:	60443-0189
Country	:	US
Telephone Number	:	708-747-5850
Fax Number	:	708-747-9991

Provider Business Practice Location Address
First Line	:	1030 N CLARK ST
Second Line	:	SUITE 400
City	:	CHICAGO
State	:	IL
Zip	:	60610-5467
Country	:	US
Telephone Number	:	312-943-6964
Fax Number	:	312-943-6924

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ALETA CLARK
Credential	:	M.D.
Telephone Number	:	312-943-6964

Provider Enumeration Date	:	10/24/2005
Last Update Date	:	11/25/2009

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