MEDICARE: PRENDERGAST PEDIATRICS P.C.

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	225X00000X	Occupational Therapist	056-008197	IL

General Provider Information

NPI Number	:	1740532126
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRENDERGAST PEDIATRICS P.C.

Provider Business Mailing Address
First Line	:	547 W SURF ST
Second Line	:	UNIT 4
City	:	CHICAGO
State	:	IL
Zip	:	60657-6034
Country	:	US
Telephone Number	:	810-656-2863
Fax Number	:

Provider Business Practice Location Address
First Line	:	547 W SURF ST
Second Line	:	UNIT 4
City	:	CHICAGO
State	:	IL
Zip	:	60657-6034
Country	:	US
Telephone Number	:	810-656-2863
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. MICHAJA LYNN PRENDERGAST
Credential	:	M.S. OTR/L
Telephone Number	:	810-656-2863

Provider Enumeration Date	:	10/09/2012
Last Update Date	:	10/09/2012

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