=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316154784
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY T ROHAN CWOCN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2800 W 95TH ST
-----------------------------------------------------
City | EVERGREEN PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60805-2701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-229-6060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2232 W 110TH ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60643-3216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-445-0913
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 364S00000X
-----------------------------------------------------
Taxonomy Name | Clinical Nurse Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------