MEDICARE: NORWEGIAN LUTHERAN BETHESDA HOME 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	314000000X	Skilled Nursing Facility	0012229	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5034709	OTHER	IL	AETNA PROVIDER #
2	01146	OTHER	IL	BCBS PROVIDER #

General Provider Information

NPI Number	:	1750378923
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORWEGIAN LUTHERAN BETHESDA HOME ASSOCIATION

Provider Business Mailing Address
First Line	:	2833 N NORDICA AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-4726
Country	:	US
Telephone Number	:	773-622-6144
Fax Number	:	773-622-8261

Provider Business Practice Location Address
First Line	:	2833 N NORDICA AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-4726
Country	:	US
Telephone Number	:	773-622-6144
Fax Number	:	773-622-8261

Authorized Official
Title or Position	:	CEO
Name	:	MRS. JULIE BOGGESS
Credential	:	NHA
Telephone Number	:	773-622-6144

Provider Enumeration Date	:	10/04/2005
Last Update Date	:	02/08/2012

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