=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427093251
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ILLIANA HOME MEDICAL EQUIPMENT AND SUPPLIES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2006
-----------------------------------------------------
Last Update Date | 03/07/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3510 W 79TH ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60652-1430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-778-8800
-----------------------------------------------------
Fax | 773-778-8808
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3510 W 79TH ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60652-1430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-778-8800
-----------------------------------------------------
Fax | 773-778-8808
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | RUDYARD SMITH
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 773-778-8800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 203.000570
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------