MEDICARE: PETERSON PARK ASSOCIATES, 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	314000000X	Skilled Nursing Facility	0024463	IL

General Provider Information

NPI Number	:	1649276080
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PETERSON PARK ASSOCIATES, LLC

Provider Business Mailing Address
First Line	:	6141 N PULASKI RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60646-5215
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6141 N PULASKI RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60646-5215
Country	:	US
Telephone Number	:	773-478-2000
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. MENACHEM SHABAT
Credential	:
Telephone Number	:	773-478-2000

Provider Enumeration Date	:	06/21/2005
Last Update Date	:	05/27/2022

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