MEDICARE: 26TH STREET MEDICAL, S.C.

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	174400000X	Specialist		IL

General Provider Information

NPI Number	:	1053518720
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	26TH STREET MEDICAL, S.C.

Provider Business Mailing Address
First Line	:	3814 W 26TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60623-3807
Country	:	US
Telephone Number	:	773-522-5200
Fax Number	:	773-522-5356

Provider Business Practice Location Address
First Line	:	3814 W 26TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60623-3807
Country	:	US
Telephone Number	:	773-522-5200
Fax Number	:	773-522-5356

Authorized Official
Title or Position	:	OFFICE ADMINISTRATOR
Name	:	MRS. ANNA SAUCEDO
Credential	:	BS
Telephone Number	:	773-522-5200

Provider Enumeration Date	:	06/27/2007
Last Update Date	:	03/19/2008

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