MEDICARE: GLEN MORTON MEDICAL CENTER, 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	207RH0003X	Hematology & Oncology Physician	042006744	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	966420	OTHER	IL	MEDICARE GROUP

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	042-006744	OTHER	IL	MEDICAL CORP.LICENSE

General Provider Information

NPI Number	:	1073525754
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLEN MORTON MEDICAL CENTER, S.C.

Provider Business Mailing Address
First Line	:	9129 WAUKEGAN RD
Second Line	:
City	:	MORTON GROVE
State	:	IL
Zip	:	60053-2120
Country	:	US
Telephone Number	:	847-965-3200
Fax Number	:	847-965-3301

Provider Business Practice Location Address
First Line	:	9129 WAUKEGAN RD
Second Line	:
City	:	MORTON GROVE
State	:	IL
Zip	:	60053-2120
Country	:	US
Telephone Number	:	847-965-3200
Fax Number	:	847-965-3270

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	DONNA M KRUEGER
Credential	:	R.N., O.C.N.
Telephone Number	:	847-965-3200

Provider Enumeration Date	:	08/12/2006
Last Update Date	:	12/15/2009

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Directions to “GLEN MORTON MEDICAL CENTER, S.C. ” Practice Location

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