=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184701328
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BERWYN EMERGENCY SERVICES SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2006
-----------------------------------------------------
Last Update Date | 09/30/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3635 HARLEM AVE
-----------------------------------------------------
City | BERWYN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60402-3212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-447-9402
-----------------------------------------------------
Fax | 708-447-3246
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3635 HARLEM AVE
-----------------------------------------------------
City | BERWYN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60402-3212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-447-9402
-----------------------------------------------------
Fax | 708-447-3246
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MANOHAR L JETHANI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 708-447-9402
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 036046173
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------