MEDICARE: GALILEE MEDICAL CENTER S.C.

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	208D00000X	General Practice Physician	042-616-998	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	31604553	OTHER	IL	BCBS OF ILL

General Provider Information

NPI Number	:	1437104239
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GALILEE MEDICAL CENTER S.C.

Provider Business Mailing Address
First Line	:	4941 N. KEDZIE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625
Country	:	US
Telephone Number	:	773-509-9099
Fax Number	:	773-509-9006

Provider Business Practice Location Address
First Line	:	4941 N. KEDZIE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625
Country	:	US
Telephone Number	:	773-509-9099
Fax Number	:	773-509-9006

Authorized Official
Title or Position	:	OWNER
Name	:	MR. NASER RUSTOM
Credential	:	M.D.
Telephone Number	:	773-561-9100

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	03/04/2009

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