MEDICARE: MERCY HOUSING LAKEFRONT

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

General Provider Information

NPI Number	:	1134390826
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MERCY HOUSING LAKEFRONT

Provider Business Mailing Address
First Line	:	247 S STATE ST
Second Line	:	SUITE 810
City	:	CHICAGO
State	:	IL
Zip	:	60604-2053
Country	:	US
Telephone Number	:	312-447-4550
Fax Number	:	312-447-4750

Provider Business Practice Location Address
First Line	:	1521 S WABASH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60605-2919
Country	:	US
Telephone Number	:	312-447-4695
Fax Number	:	312-447-4764

Authorized Official
Title or Position	:	V.P., COMMUNITY SUPPORTIVE SERVICES
Name	:	MR. FELIX R. MATLOCK
Credential	:
Telephone Number	:	312-447-4532

Provider Enumeration Date	:	03/20/2008
Last Update Date	:	03/20/2008

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