MEDICARE: LIFESCAN CHICAGO 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	261QR0200X	Radiology Clinic/Center

General Provider Information

NPI Number	:	1356344378
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFESCAN CHICAGO LLC

Provider Business Mailing Address
First Line	:	2242 W HARRISON ST
Second Line	:	STE 100
City	:	CHICAGO
State	:	IL
Zip	:	60612-3515
Country	:	US
Telephone Number	:	312-243-3200
Fax Number	:	312-243-5759

Provider Business Practice Location Address
First Line	:	2242 W HARRISON ST
Second Line	:	STE 100
City	:	CHICAGO
State	:	IL
Zip	:	60612-3515
Country	:	US
Telephone Number	:	312-243-3200
Fax Number	:	312-243-5759

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	MRS. MARY SOTO
Credential	:
Telephone Number	:	708-452-6842

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	05/06/2009

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Directions to “LIFESCAN CHICAGO LLC ” Practice Location

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