=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275704124
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MCGAW MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2008
-----------------------------------------------------
Last Update Date | 03/19/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 675 N SAINT CLAIR ST SUITE 18-200
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-5975
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-695-8630
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 675 N SAINT CLAIR ST SUITE 18-200
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-5975
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROGRAM DIRECTOR
-----------------------------------------------------
Name | DIANE WAYNE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 312-695-8630
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282E00000X
-----------------------------------------------------
Taxonomy Name | Long Term Care Hospital
-----------------------------------------------------
License Number | AN5240394-9871
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------