MEDICARE: NANCY J SHORT MD 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	207Q00000X	Family Medicine Physician	036103076	IL

General Provider Information

NPI Number	:	1588732150
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NANCY J SHORT MD LLC

Provider Business Mailing Address
First Line	:	4360 KENNEDY DR
Second Line	:	SUITE 1
City	:	EAST MOLINE
State	:	IL
Zip	:	61244-4287
Country	:	US
Telephone Number	:	309-792-6090
Fax Number	:	309-792-6097

Provider Business Practice Location Address
First Line	:	4360 KENNEDY DR
Second Line	:	SUITE 1
City	:	EAST MOLINE
State	:	IL
Zip	:	61244-4287
Country	:	US
Telephone Number	:	309-792-6090
Fax Number	:	309-792-6097

Authorized Official
Title or Position	:	OWNER
Name	:	DR. NANCY J SHORT
Credential	:	MD
Telephone Number	:	309-792-6090

Provider Enumeration Date	:	12/01/2006
Last Update Date	:	10/30/2008

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