MEDICARE: MARIANJOY AT PROVIDENCE PALOS HEIGHTS

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	283X00000X	Rehabilitation Hospital
2	314000000X	Skilled Nursing Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	50426	OTHER	IL	BLUE CROSS BLUE SHIELD ILLINOIS

General Provider Information

NPI Number	:	1649404245
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARIANJOY AT PROVIDENCE PALOS HEIGHTS

Provider Business Mailing Address
First Line	:	13259 S CENTRAL AVE
Second Line	:
City	:	PALOS HEIGHTS
State	:	IL
Zip	:	60463-2601
Country	:	US
Telephone Number	:	630-909-7378
Fax Number	:	630-909-7371

Provider Business Practice Location Address
First Line	:	13259 S CENTRAL AVE
Second Line	:
City	:	PALOS HEIGHTS
State	:	IL
Zip	:	60463-2601
Country	:	US
Telephone Number	:	630-909-7378
Fax Number	:	630-909-7371

Authorized Official
Title or Position	:	PATIENT ACCOUNT MANAGER
Name	:	JACQUE' BARNES
Credential	:
Telephone Number	:	603-909-7378

Provider Enumeration Date	:	05/11/2009
Last Update Date	:	02/11/2013

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