MEDICARE: WOODBRIDGE NURSING PAVILION, LTD.

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	0034157	IL

General Provider Information

NPI Number	:	1821075474
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WOODBRIDGE NURSING PAVILION, LTD.

Provider Business Mailing Address
First Line	:	3359 MAIN ST
Second Line	:
City	:	SKOKIE
State	:	IL
Zip	:	60076-2432
Country	:	US
Telephone Number	:	847-679-8219
Fax Number	:	847-679-7377

Provider Business Practice Location Address
First Line	:	2242 N KEDZIE BLVD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-2504
Country	:	US
Telephone Number	:	773-486-7700
Fax Number	:	773-486-7937

Authorized Official
Title or Position	:	SECRETARY-TREASURER
Name	:	MR. MARSHALL A MAUER
Credential	:
Telephone Number	:	847-679-8219

Provider Enumeration Date	:	12/26/2005
Last Update Date	:	11/23/2011

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