Healthcare Provider Details

I. General information

NPI: 1588617260
Provider Name (Legal Business Name): LITTLE COMPANY OF MARY AFFILIATED SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 02/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 W 95TH ST
EVERGREEN PARK IL
60805-2701
US

IV. Provider business mailing address

2800 W 95TH ST
EVERGREEN PARK IL
60805-2701
US

V. Phone/Fax

Practice location:
  • Phone: 708-229-5171
  • Fax: 708-229-4209
Mailing address:
  • Phone: 708-229-5171
  • Fax: 708-229-4209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: CAROL A HEENAN
Title or Position: DIRECTOR PROFESSIONAL SERVICES
Credential:
Phone: 708-229-5171