MEDICARE: M.D DEVELOPMENTAL AGENCY LLC

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	252Y00000X	Early Intervention Provider Agency

General Provider Information

NPI Number	:	1386181675
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	M.D DEVELOPMENTAL AGENCY LLC

Provider Business Mailing Address
First Line	:	1501 E 72ND ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60619-1511
Country	:	US
Telephone Number	:	773-407-7558
Fax Number	:

Provider Business Practice Location Address
First Line	:	3335 S INDIANA AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-3838
Country	:	US
Telephone Number	:	708-253-9271
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DEBRA STEWART
Credential	:
Telephone Number	:	773-407-7558

Provider Enumeration Date	:	01/24/2017
Last Update Date	:	01/24/2017

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