MEDICARE: GRANT PARK COMMUNITY UNIT DISTRICT 6

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	251300000X	Local Education Agency (LEA)	32046006026	IL

General Provider Information

NPI Number	:	1538347695
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRANT PARK COMMUNITY UNIT DISTRICT 6

Provider Business Mailing Address
First Line	:	PO BOX 549
Second Line	:
City	:	GRANT PARK
State	:	IL
Zip	:	60940-0549
Country	:	US
Telephone Number	:	815-465-6013
Fax Number	:	815-465-2505

Provider Business Practice Location Address
First Line	:	421 ESSON FARM RD
Second Line	:
City	:	GRANT PARK
State	:	IL
Zip	:	60940-7262
Country	:	US
Telephone Number	:	815-465-6013
Fax Number	:	815-465-2505

Authorized Official
Title or Position	:	SUPERINTENDENT
Name	:	DR. MICHAEL THOMAS NICHOLSON
Credential	:
Telephone Number	:	815-465-6013

Provider Enumeration Date	:	01/31/2008
Last Update Date	:	04/20/2008

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