MEDICARE: JEFFERSON PARK MEDICAL CENTER

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	261QM2500X	Medical Specialty Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194934208
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JEFFERSON PARK MEDICAL CENTER

Provider Business Mailing Address
First Line	:	4955 N MILWAUKEE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-2286
Country	:	US
Telephone Number	:	630-209-8405
Fax Number	:	773-736-1403

Provider Business Practice Location Address
First Line	:	4955 N MILWAUKEE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-2286
Country	:	US
Telephone Number	:	630-209-8405
Fax Number	:	773-736-1403

Authorized Official
Title or Position	:	OPERATIONS MANAGER
Name	:	PIERRE CHATELAIN
Credential	:
Telephone Number	:	630-209-8405

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	07/10/2008

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