MEDICARE: GATEWAY HEALTH SYSTEMS, INC.

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	251E00000X	Home Health Agency	1010178	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1010178	OTHER	IL	STATE AGENCY LICENSE NUMB

General Provider Information

NPI Number	:	1396827317
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GATEWAY HEALTH SYSTEMS, INC.

Provider Business Mailing Address
First Line	:	2902 ALEXANDER CRES
Second Line	:
City	:	FLOSSMOOR
State	:	IL
Zip	:	60422-1704
Country	:	US
Telephone Number	:	708-754-9674
Fax Number	:	708-754-9796

Provider Business Practice Location Address
First Line	:	222 VOLLMER RD
Second Line	:
City	:	CHICAGO HEIGHTS
State	:	IL
Zip	:	60411-1664
Country	:	US
Telephone Number	:	708-754-9674
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	DR. AJIBOLA A AYENI
Credential	:	PHD, MD
Telephone Number	:	708-754-9674

Provider Enumeration Date	:	10/19/2006
Last Update Date	:	08/22/2020

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