=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306076484
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE MATHER EVANSTON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2009
-----------------------------------------------------
Last Update Date | 02/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 425 DAVIS ST
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60201-4693
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-492-7500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 425 DAVIS ST
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60201-4693
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-492-7500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | MARY G. LEARY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-492-7715
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | LC 03-08
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------