=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851650360
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JESSE BROWN VA MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2012
-----------------------------------------------------
Last Update Date | 05/04/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 820 S DAMEN AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60612-3728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-569-6911
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 820 S DAMEN AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60612-3728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL NUTRITION MANAGER
-----------------------------------------------------
Name | MARGARET MYSLINSKY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 312-569-6911
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282N00000X
-----------------------------------------------------
Taxonomy Name | General Acute Care Hospital
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------