MEDICARE: CENTENNIAL MEDICAL MANAGEMENT

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	333600000X	Pharmacy		IL

General Provider Information

NPI Number	:	1558340893
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTENNIAL MEDICAL MANAGEMENT

Provider Business Mailing Address
First Line	:	1044 N FRANCISCO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-2743
Country	:	US
Telephone Number	:	773-292-8260
Fax Number	:	773-292-5979

Provider Business Practice Location Address
First Line	:	1044 N FRANCISCO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-2743
Country	:	US
Telephone Number	:	773-292-8260
Fax Number	:	773-292-5979

Authorized Official
Title or Position	:	CFO
Name	:	MR. WILLIAM GROEPER
Credential	:
Telephone Number	:	773-292-8200

Provider Enumeration Date	:	01/13/2006
Last Update Date	:	08/22/2020

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