MEDICARE: THE MEDICAL & SURGICAL CENTER OF ILLINOIS

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	261QP1100X	Podiatric Clinic/Center

General Provider Information

NPI Number	:	1639343049
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE MEDICAL & SURGICAL CENTER OF ILLINOIS

Provider Business Mailing Address
First Line	:	3818 NOTTINGHAM DR
Second Line	:
City	:	LONG GROVE
State	:	IL
Zip	:	60047-5240
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3818 NOTTINGHAM DR
Second Line	:
City	:	LONG GROVE
State	:	IL
Zip	:	60047-5240
Country	:	US
Telephone Number	:	847-808-3338
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. PAUL POTACH
Credential	:
Telephone Number	:	847-808-3338

Provider Enumeration Date	:	04/16/2008
Last Update Date	:	04/16/2008

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