MEDICARE: MARIAM M ELDEIB I MSW, LCSW

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	1041C0700X	Clinical Social Worker	149.015745	IL

General Provider Information

NPI Number	:	1265855209
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIAM M ELDEIB I MSW, LCSW

Provider Business Mailing Address
First Line	:	675 N SAINT CLAIR ST
Second Line	:	SUITE 21-100
City	:	CHICAGO
State	:	IL
Zip	:	60611-5975
Country	:	US
Telephone Number	:	312-926-7377
Fax Number	:

Provider Business Practice Location Address
First Line	:	38205 EAGLE WAY
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60678-1382
Country	:	US
Telephone Number	:	312-695-9797
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/28/2014
Last Update Date	:	01/28/2014

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