MEDICARE: MCDERMOTT CENTER

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	324500000X	Substance Abuse Rehabilitation Facility	A-0349-0055	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	:	1447638002
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MCDERMOTT CENTER

Provider Business Mailing Address
First Line	:	932 WEST WASHINGTON BLVD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607
Country	:	US
Telephone Number	:	312-226-7984
Fax Number	:	312-226-8048

Provider Business Practice Location Address
First Line	:	932 W WASHINGTON BLVD
Second Line	:	3RD FLOOR, ROOMS 303,304,305,307
City	:	CHICAGO
State	:	IL
Zip	:	60607-2217
Country	:	US
Telephone Number	:	312-226-7984
Fax Number	:	312-226-8048

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	DR. DAN LUSTIG
Credential	:
Telephone Number	:	312-226-7984

Provider Enumeration Date	:	05/14/2015
Last Update Date	:	04/09/2022

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Directions to “MCDERMOTT CENTER ” Practice Location

Language	Start Address	Practice Location

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