MEDICARE: PENTOM HEALTH SERVICES 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	363LF0000X	Family Nurse Practitioner

General Provider Information

NPI Number	:	1366125536
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PENTOM HEALTH SERVICES LLC

Provider Business Mailing Address
First Line	:	516 GRANT ST
Second Line	:
City	:	DOWNERS GROVE
State	:	IL
Zip	:	60515-3024
Country	:	US
Telephone Number	:	630-413-1303
Fax Number	:

Provider Business Practice Location Address
First Line	:	516 GRANT ST
Second Line	:
City	:	DOWNERS GROVE
State	:	IL
Zip	:	60515-3024
Country	:	US
Telephone Number	:	630-413-1303
Fax Number	:	888-311-3015

Authorized Official
Title or Position	:	CEO
Name	:	MARCIA RADJA
Credential	:	FNP
Telephone Number	:	312-420-5494

Provider Enumeration Date	:	08/14/2023
Last Update Date	:	08/14/2023

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