MEDICARE: POLISH AMERICAN ASSOCIATION

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	253Z00000X	In Home Supportive Care Agency	1346682614	IL

General Provider Information

NPI Number	:	1730505967
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POLISH AMERICAN ASSOCIATION

Provider Business Mailing Address
First Line	:	3834 N CICERO AVE
Second Line	:	ATTN: ACCOUNTING DEPARTMENT
City	:	CHICAGO
State	:	IL
Zip	:	60641-3622
Country	:	US
Telephone Number	:	773-282-8206
Fax Number	:	773-282-1324

Provider Business Practice Location Address
First Line	:	3834 N CICERO AVE
Second Line	:	ATTN: ACCOUNTING DEPARTMENT
City	:	CHICAGO
State	:	IL
Zip	:	60641-3622
Country	:	US
Telephone Number	:	773-282-8206
Fax Number	:	773-282-1324

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. GARY KENZER
Credential	:
Telephone Number	:	773-427-6317

Provider Enumeration Date	:	03/12/2014
Last Update Date	:	03/12/2014

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Practice Location Address:

3834 N CICERO AVE
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Practice Location Address:

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Directions to “POLISH AMERICAN ASSOCIATION ” Practice Location

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