MEDICARE: BETHANY HOMES AND METHODIST HOSPITAL

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	207Q00000X	Family Medicine Physician	036108645	IL

General Provider Information

NPI Number	:	1518202225
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BETHANY HOMES AND METHODIST HOSPITAL

Provider Business Mailing Address
First Line	:	5113 N CLARK ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-2807
Country	:	US
Telephone Number	:	773-293-4090
Fax Number	:	773-293-4503

Provider Business Practice Location Address
First Line	:	5113 N CLARK ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-2807
Country	:	US
Telephone Number	:	773-293-4090
Fax Number	:	773-293-4503

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. CAMILLA LARSEN
Credential	:	M.D.
Telephone Number	:	773-653-5630

Provider Enumeration Date	:	12/06/2012
Last Update Date	:	12/20/2012

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