MEDICARE: LUTHERAN SOCIAL SERVICES 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	2084P0804X	Child & Adolescent Psychiatry Physician
2	2084P0800X	Psychiatry Physician

General Provider Information

NPI Number	:	1720203326
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LUTHERAN SOCIAL SERVICES OF ILLINOIS

Provider Business Mailing Address
First Line	:	1001 E TOUHY AVE
Second Line	:	SUITE 170
City	:	DES PLAINES
State	:	IL
Zip	:	60018-5801
Country	:	US
Telephone Number	:	847-635-4600
Fax Number	:	847-297-3407

Provider Business Practice Location Address
First Line	:	6321 N AVONDALE AVE
Second Line	:	SUITE A 101
City	:	CHICAGO
State	:	IL
Zip	:	60631-1900
Country	:	US
Telephone Number	:	773-774-7555
Fax Number	:	773-774-8910

Authorized Official
Title or Position	:	CHIEF FINANCIAL OFFICER
Name	:	MR. GERALD NOONAN
Credential	:
Telephone Number	:	847-635-4600

Provider Enumeration Date	:	04/17/2007
Last Update Date	:	06/19/2008

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Directions to “LUTHERAN SOCIAL SERVICES OF ILLINOIS ” Practice Location

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