MEDICARE: HSHS MEDICAL GROUP

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	282NC2000X	Children's Hospital	036125483	IL

General Provider Information

NPI Number	:	1265752844
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HSHS MEDICAL GROUP

Provider Business Mailing Address
First Line	:	1900 E LAKE SHORE DR STE 330
Second Line	:	SUITE 330
City	:	DECATUR
State	:	IL
Zip	:	62521-3848
Country	:	US
Telephone Number	:	217-423-2889
Fax Number	:

Provider Business Practice Location Address
First Line	:	1900 E LAKE SHORE DR STE 330
Second Line	:	SUITE 330
City	:	DECATUR
State	:	IL
Zip	:	62521-3848
Country	:	US
Telephone Number	:	217-423-2889
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT &CHIEF EXECUTIVE OFFICER
Name	:	DR. RICHARD ROLSTAN
Credential	:	M.D
Telephone Number	:	217-523-4747

Provider Enumeration Date	:	06/07/2010
Last Update Date	:	09/07/2010

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