MEDICARE: CRG EM OPERATOR, 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	313M00000X	Nursing Facility/Intermediate Care Facility
2	314000000X	Skilled Nursing Facility

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	14-6041	OTHER		MEDICARE CERTIFICATION NUMBER

General Provider Information

NPI Number	:	1558670455
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRG EM OPERATOR, LLC

Provider Business Mailing Address
First Line	:	10 SUDBROOK LN STE 102
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21208-4147
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	430 30TH AVE
Second Line	:
City	:	EAST MOLINE
State	:	IL
Zip	:	61244-3152
Country	:	US
Telephone Number	:	309-755-3466
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	JEFFREY KAGAN
Credential	:
Telephone Number	:	410-877-6630

Provider Enumeration Date	:	09/27/2010
Last Update Date	:	02/11/2011

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Directions to “CRG EM OPERATOR, LLC ” Practice Location

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