MEDICARE: LISBON GRADE SCHOOL #90

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	251300000X	Local Education Agency (LEA)

General Provider Information

NPI Number	:	1417000670
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LISBON GRADE SCHOOL #90

Provider Business Mailing Address
First Line	:	127 S CANAL ST
Second Line	:
City	:	NEWARK
State	:	IL
Zip	:	60541-9776
Country	:	US
Telephone Number	:	815-736-6324
Fax Number	:	815-736-6326

Provider Business Practice Location Address
First Line	:	127 S CANAL ST
Second Line	:
City	:	NEWARK
State	:	IL
Zip	:	60541-9776
Country	:	US
Telephone Number	:	815-736-6324
Fax Number	:	815-736-6326

Authorized Official
Title or Position	:	SUPERINTENDENT
Name	:	MR. MICHAEL RUSTMAN
Credential	:
Telephone Number	:	815-736-6324

Provider Enumeration Date	:	01/19/2007
Last Update Date	:	08/22/2020

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