MEDICARE: PERFUSION SOURCE LTD

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	343900000X	Non-emergency Medical Transport (VAN)	6519 MC	IL

General Provider Information

NPI Number	:	1629242987
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERFUSION SOURCE LTD

Provider Business Mailing Address
First Line	:	7725 S EAST END AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60649-4503
Country	:	US
Telephone Number	:	773-731-7373
Fax Number	:

Provider Business Practice Location Address
First Line	:	7725 S EAST END AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60649-4503
Country	:	US
Telephone Number	:	773-731-7373
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. BERNARD WASHINGTON
Credential	:	CCP
Telephone Number	:	773-731-7373

Provider Enumeration Date	:	04/17/2008
Last Update Date	:	04/17/2008

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