MEDICARE: PAVILION OF LOGAN SQUARE LLC

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	314000000X	Skilled Nursing Facility

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	:	1588302137
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAVILION OF LOGAN SQUARE LLC

Provider Business Mailing Address
First Line	:	3755 CHASE AVE
Second Line	:
City	:	SKOKIE
State	:	IL
Zip	:	60076-4008
Country	:	US
Telephone Number	:	224-470-2044
Fax Number	:	224-470-2952

Provider Business Practice Location Address
First Line	:	2242 N KEDZIE BLVD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-2504
Country	:	US
Telephone Number	:	773-486-7700
Fax Number	:	773-486-7937

Authorized Official
Title or Position	:	CFO
Name	:	MARCELLA GRAF
Credential	:
Telephone Number	:	224-470-2044

Provider Enumeration Date	:	05/24/2022
Last Update Date	:	11/04/2025

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Directions to “PAVILION OF LOGAN SQUARE LLC ” Practice Location

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