MEDICARE: MRS. JEANMARIE RICHARDS PA-C

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	363AM0700X	Medical Physician Assistant		IL

General Provider Information

NPI Number	:	1629152061
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JEANMARIE RICHARDS PA-C

Provider Business Mailing Address
First Line	:	13937 W MEATH DR
Second Line	:
City	:	HOMER GLEN
State	:	IL
Zip	:	60491-7704
Country	:	US
Telephone Number	:	815-722-7000
Fax Number	:	815-722-7180

Provider Business Practice Location Address
First Line	:	72 N CHICAGO ST
Second Line	:
City	:	JOLIET
State	:	IL
Zip	:	60432-4315
Country	:	US
Telephone Number	:	815-722-7000
Fax Number	:	815-722-7180

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/24/2006
Last Update Date	:	07/09/2007

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