MEDICARE: HOME SLEEP DIAGNOSTICS

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	261QS1200X	Sleep Disorder Diagnostic Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0001620869	OTHER	IL	BCBS PROVIDER #

General Provider Information

NPI Number	:	1881707891
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOME SLEEP DIAGNOSTICS

Provider Business Mailing Address
First Line	:	2522 W PETERSON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-4109
Country	:	US
Telephone Number	:	773-262-4110
Fax Number	:	773-784-0701

Provider Business Practice Location Address
First Line	:	2522 W PETERSON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-4109
Country	:	US
Telephone Number	:	773-262-4110
Fax Number	:	773-784-0701

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. AHUVA ELANA SHABAT
Credential	:
Telephone Number	:	773-262-4110

Provider Enumeration Date	:	08/16/2006
Last Update Date	:	08/28/2007

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Directions to “HOME SLEEP DIAGNOSTICS ” Practice Location

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