MEDICARE: PAULA FONGER RN

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	163W00000X	Registered Nurse	041325622	IL

General Provider Information

NPI Number	:	1063821031
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAULA FONGER RN

Provider Business Mailing Address
First Line	:	2215 SANDERS RD
Second Line	:	SUITE 105
City	:	NORTHBROOK
State	:	IL
Zip	:	60062-6126
Country	:	US
Telephone Number	:	224-330-6300
Fax Number	:	224-330-6325

Provider Business Practice Location Address
First Line	:	572 LINCOLN AVE
Second Line	:	SUITE 3
City	:	WINNETKA
State	:	IL
Zip	:	60093-2308
Country	:	US
Telephone Number	:	847-501-4040
Fax Number	:	847-501-4075

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/04/2014
Last Update Date	:	08/04/2014

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