MEDICARE: EVERGREEN EMERGENCY SERVICES, 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	207PE0004X	Emergency Medical Services (Emergency Medicine) Physician		IL

General Provider Information

NPI Number	:	1881679678
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGREEN EMERGENCY SERVICES, LTD

Provider Business Mailing Address
First Line	:	PO BOX 42898
Second Line	:
City	:	EVERGREEN PARK
State	:	IL
Zip	:	60805-0898
Country	:	US
Telephone Number	:	708-422-4221
Fax Number	:	708-422-4415

Provider Business Practice Location Address
First Line	:	2800 W 95TH ST
Second Line	:
City	:	EVERGREEN PARK
State	:	IL
Zip	:	60805-2701
Country	:	US
Telephone Number	:	708-422-4221
Fax Number	:	708-422-4415

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	KATHLEEN GUERRERO
Credential	:
Telephone Number	:	708-422-4221

Provider Enumeration Date	:	12/14/2005
Last Update Date	:	10/16/2015

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