MEDICARE: ST. MARY OF PROVIDENCE DEVELOPMENTAL TRAINING PROGRAM

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	251C00000X	Developmentally Disabled Services Day Training Agency	36217748	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609224328
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. MARY OF PROVIDENCE DEVELOPMENTAL TRAINING PROGRAM

Provider Business Mailing Address
First Line	:	4200 N AUSTIN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-1615
Country	:	US
Telephone Number	:	773-545-8300
Fax Number	:

Provider Business Practice Location Address
First Line	:	4200 N AUSTIN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-1615
Country	:	US
Telephone Number	:	773-545-8300
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	CHARLEEN M BADIOLA
Credential	:
Telephone Number	:	773-545-8300

Provider Enumeration Date	:	06/03/2016
Last Update Date	:	06/03/2016

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