MEDICARE: GLORIA S. PARK RN

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	163W00000X	Registered Nurse		IL

General Provider Information

NPI Number	:	1992755862
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLORIA S. PARK RN

Provider Business Mailing Address
First Line	:	4009 N KILDARE AVE
Second Line	:	303
City	:	CHICAGO
State	:	IL
Zip	:	60641-1944
Country	:	US
Telephone Number	:	847-912-7587
Fax Number	:

Provider Business Practice Location Address
First Line	:	4009 N KILDARE AVE
Second Line	:	303
City	:	CHICAGO
State	:	IL
Zip	:	60641-1944
Country	:	US
Telephone Number	:	847-912-7587
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/11/2006
Last Update Date	:	07/08/2007

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