MEDICARE: ILLIANA HOME MEDICAL EQUIPMENT AND SUPPLIES 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	332B00000X	Durable Medical Equipment & Medical Supplies	203.000570	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	203.000570	OTHER	IL	LICENSE NO

General Provider Information

NPI Number	:	1427093251
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ILLIANA HOME MEDICAL EQUIPMENT AND SUPPLIES LLC

Provider Business Mailing Address
First Line	:	3510 W 79TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60652-1430
Country	:	US
Telephone Number	:	773-778-8800
Fax Number	:	773-778-8808

Provider Business Practice Location Address
First Line	:	3510 W 79TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60652-1430
Country	:	US
Telephone Number	:	773-778-8800
Fax Number	:	773-778-8808

Authorized Official
Title or Position	:	MEMBER
Name	:	RUDYARD SMITH
Credential	:	MD
Telephone Number	:	773-778-8800

Provider Enumeration Date	:	06/17/2006
Last Update Date	:	03/07/2012

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