MEDICARE: PORTAGE PARK SATELLITE SENIOR CENTER

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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1366610206
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PORTAGE PARK SATELLITE SENIOR CENTER

Provider Business Mailing Address
First Line	:	4100 N LONG AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-1346
Country	:	US
Telephone Number	:	312-744-9022
Fax Number	:

Provider Business Practice Location Address
First Line	:	4100 N LONG AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-1346
Country	:	US
Telephone Number	:	312-744-9022
Fax Number	:

Authorized Official
Title or Position	:	DEPUTY COMMISSIONER
Name	:	DR. GRETA IVERS
Credential	:	MD, MPH
Telephone Number	:	312-744-0890

Provider Enumeration Date	:	02/13/2008
Last Update Date	:	02/13/2008

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