MEDICARE: ADOLESCENT AND YOUNG ADULT PLACE LTD

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	2080A0000X	Pediatric Adolescent Medicine Physician	036086432	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417259979
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADOLESCENT AND YOUNG ADULT PLACE LTD

Provider Business Mailing Address
First Line	:	PO BOX 795
Second Line	:
City	:	HILLSIDE
State	:	IL
Zip	:	60162-0795
Country	:	US
Telephone Number	:	708-544-6553
Fax Number	:

Provider Business Practice Location Address
First Line	:	9 N CICERO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60644-3602
Country	:	US
Telephone Number	:	312-859-2491
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MARGO ANTOINETTE BELL
Credential	:	M.D.
Telephone Number	:	312-859-2491

Provider Enumeration Date	:	12/03/2010
Last Update Date	:	12/03/2010

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