MEDICARE: 4621 CORPORATION

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	0023770

General Provider Information

NPI Number	:	1871580126
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	4621 CORPORATION

Provider Business Mailing Address
First Line	:	405 N WABASH AVE STE P2W
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-3541
Country	:	US
Telephone Number	:	312-787-9400
Fax Number	:	312-787-9434

Provider Business Practice Location Address
First Line	:	4621 N RACINE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-4905
Country	:	US
Telephone Number	:	773-784-2300
Fax Number	:	773-769-4621

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. PETER J OBRIEN SR.
Credential	:
Telephone Number	:	312-787-9400

Provider Enumeration Date	:	10/03/2005
Last Update Date	:	04/08/2019

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