MEDICARE: ELM CITY REHABILITATION CENTER, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251B00000X	Case Management Agency
2	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1023258456
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELM CITY REHABILITATION CENTER, INC.

Provider Business Mailing Address
First Line	:	1314 W WALNUT ST
Second Line	:
City	:	JACKSONVILLE
State	:	IL
Zip	:	62650-1148
Country	:	US
Telephone Number	:	217-245-9504
Fax Number	:	217-243-2350

Provider Business Practice Location Address
First Line	:	310 N MAIN ST
Second Line	:
City	:	JACKSONVILLE
State	:	IL
Zip	:	62650-2021
Country	:	US
Telephone Number	:	217-245-9504
Fax Number	:	217-243-2350

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	MR. THOMAS FREDERICK
Credential	:
Telephone Number	:	217-245-9504

Provider Enumeration Date	:	02/25/2009
Last Update Date	:	02/25/2009

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