MEDICARE: SOUTH LAKE MEDICAL SERVICES, 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	261QA0600X	Adult Day Care Clinic/Center	036049708	IL

General Provider Information

NPI Number	:	1407023849
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH LAKE MEDICAL SERVICES, LTD

Provider Business Mailing Address
First Line	:	2621 E 75TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60649-3705
Country	:	US
Telephone Number	:	773-375-1900
Fax Number	:	773-375-8279

Provider Business Practice Location Address
First Line	:	2621 E 75TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60649-3705
Country	:	US
Telephone Number	:	773-375-1900
Fax Number	:	773-375-8279

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MARIA C THACHENKERY
Credential	:	M.D
Telephone Number	:	773-375-1900

Provider Enumeration Date	:	05/14/2008
Last Update Date	:	05/14/2008

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