MEDICARE: LITTLE COMPANY OF MARY AFFILIATED SERVICES INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	207V00000X	Obstetrics & Gynecology Physician
2	2084P0800X	Psychiatry Physician
3	208600000X	Surgery Physician
4	207R00000X	Internal Medicine Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CC2999	OTHER	IL	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	01620807	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1588617260
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LITTLE COMPANY OF MARY AFFILIATED SERVICES INC

Provider Business Mailing Address
First Line	:	2800 W 95TH ST
Second Line	:
City	:	EVERGREEN PARK
State	:	IL
Zip	:	60805-2701
Country	:	US
Telephone Number	:	708-229-5171
Fax Number	:	708-229-4209

Provider Business Practice Location Address
First Line	:	2800 W 95TH ST
Second Line	:
City	:	EVERGREEN PARK
State	:	IL
Zip	:	60805-2701
Country	:	US
Telephone Number	:	708-229-5171
Fax Number	:	708-229-4209

Authorized Official
Title or Position	:	DIRECTOR PROFESSIONAL SERVICES
Name	:	CAROL A HEENAN
Credential	:
Telephone Number	:	708-229-5171

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	02/22/2010

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Directions to “LITTLE COMPANY OF MARY AFFILIATED SERVICES INC ” Practice Location

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