MEDICARE: ST. MARY OF PROVIDENCE

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	315P00000X	Intellectual Disabilities Intermediate Care Facility	0033761	IL

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	:	1588842470
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. MARY OF PROVIDENCE

Provider Business Mailing Address
First Line	:	4200 N AUSTIN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-1615
Country	:	US
Telephone Number	:	773-545-8300
Fax Number	:	773-545-2984

Provider Business Practice Location Address
First Line	:	4200 N AUSTIN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-1615
Country	:	US
Telephone Number	:	773-545-8300
Fax Number	:	773-545-2984

Authorized Official
Title or Position	:	DIRECTOR
Name	:	RITA M BUTLER
Credential	:	R.N., NHA
Telephone Number	:	773-545-8300

Provider Enumeration Date	:	02/04/2008
Last Update Date	:	02/04/2008

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Directions to “ST. MARY OF PROVIDENCE ” Practice Location

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