MEDICARE: CLINICAL SUPPORT SERVICES, 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	363L00000X	Nurse Practitioner	209001766	IL

General Provider Information

NPI Number	:	1659503217
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLINICAL SUPPORT SERVICES, LLC

Provider Business Mailing Address
First Line	:	1501 LOCUST ST APT 906
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63103-1847
Country	:	US
Telephone Number	:	618-558-3955
Fax Number	:

Provider Business Practice Location Address
First Line	:	1501 LOCUST ST APT 906
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63103-1847
Country	:	US
Telephone Number	:	618-558-3955
Fax Number	:

Authorized Official
Title or Position	:	NURSE PRACTITIONER
Name	:	ELLEN M MILLER
Credential	:	NP
Telephone Number	:	618-558-3955

Provider Enumeration Date	:	08/17/2009
Last Update Date	:	11/30/2009

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