MEDICARE: BRIDGEMARK OF GREENVILLE, 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	313M00000X	Nursing Facility/Intermediate Care Facility	0046680	IL
2	314000000X	Skilled Nursing Facility	0046680	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0046680	OTHER	IL	FACILITY LICENSE NUMBER

General Provider Information

NPI Number	:	1386641272
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDGEMARK OF GREENVILLE, LLC

Provider Business Mailing Address
First Line	:	400 E HILLVIEW AVE
Second Line	:
City	:	GREENVILLE
State	:	IL
Zip	:	62246-2607
Country	:	US
Telephone Number	:	618-664-1622
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 E HILLVIEW AVE
Second Line	:
City	:	GREENVILLE
State	:	IL
Zip	:	62246-2607
Country	:	US
Telephone Number	:	618-664-1622
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	MR. STEPHEN P MILLER
Credential	:
Telephone Number	:	312-994-2306

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	04/29/2015

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