MEDICARE: AUSTIN PRIDE

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	1706406	IL

General Provider Information

NPI Number	:	1285809236
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AUSTIN PRIDE

Provider Business Mailing Address
First Line	:	645 S CENTRAL AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60644-5059
Country	:	US
Telephone Number	:	773-854-5000
Fax Number	:

Provider Business Practice Location Address
First Line	:	4925 W DIVISION ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60651-3159
Country	:	US
Telephone Number	:	773-854-5000
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	MR. STEVE DRUCKER
Credential	:
Telephone Number	:	773-854-5000

Provider Enumeration Date	:	04/29/2008
Last Update Date	:	04/29/2008

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Directions to “AUSTIN PRIDE ” Practice Location

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