MEDICARE: MERCY DIAGNOSTIC AND TREATMENT 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	261QF0400X	Federally Qualified Health Center (FQHC)	1884582	IL

General Provider Information

NPI Number	:	1245677848
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MERCY DIAGNOSTIC AND TREATMENT CENTER

Provider Business Mailing Address
First Line	:	3755 S COTTAGE GROVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60653
Country	:	US
Telephone Number	:	312-567-2000
Fax Number	:

Provider Business Practice Location Address
First Line	:	3755 S COTTAGE GROVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60653
Country	:	US
Telephone Number	:	312-567-2000
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	MS. IRIS CHAN
Credential	:
Telephone Number	:	312-567-6676

Provider Enumeration Date	:	05/23/2013
Last Update Date	:	05/24/2013

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