MEDICARE: DOWNERS GROVE GERIATRICS 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	207R00000X	Internal Medicine Physician	036106287	IL

General Provider Information

NPI Number	:	1700018710
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOWNERS GROVE GERIATRICS LLC

Provider Business Mailing Address
First Line	:	4411 ROSLYN RD
Second Line	:
City	:	DOWNERS GROVE
State	:	IL
Zip	:	60515-5804
Country	:	US
Telephone Number	:	630-241-3779
Fax Number	:	630-241-9309

Provider Business Practice Location Address
First Line	:	3800 HIGHLAND AVE
Second Line	:	SUITE 111
City	:	DOWNERS GROVE
State	:	IL
Zip	:	60515-1557
Country	:	US
Telephone Number	:	630-241-3779
Fax Number	:	630-241-9309

Authorized Official
Title or Position	:	MEMBER
Name	:	RACHEL MAYORGA
Credential	:	MD
Telephone Number	:	630-241-3779

Provider Enumeration Date	:	08/10/2009
Last Update Date	:	08/10/2009

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