MEDICARE: JSA OF ILLINOIS PC

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	246ZC0007X	Surgical Assistant
2	363AS0400X	Surgical Physician Assistant

General Provider Information

NPI Number	:	1689966533
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JSA OF ILLINOIS PC

Provider Business Mailing Address
First Line	:	PO BOX 543
Second Line	:
City	:	ALPHARETTA
State	:	GA
Zip	:	30009-0543
Country	:	US
Telephone Number	:	678-983-4479
Fax Number	:

Provider Business Practice Location Address
First Line	:	309 E RAND RD
Second Line	:	SUITE 347
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60004-3103
Country	:	US
Telephone Number	:	678-983-4479
Fax Number	:

Authorized Official
Title or Position	:	BILLING DIRECTOR
Name	:	ANN SCHAKER
Credential	:
Telephone Number	:	678-983-4479

Provider Enumeration Date	:	05/11/2011
Last Update Date	:	08/16/2011

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