MEDICARE: MARY JANE MARREN OTR

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	174400000X	Specialist	056001061	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0071647296	OTHER	IL	BCBS
2	0061649364	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1992845531
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY JANE MARREN OTR

Provider Business Mailing Address
First Line	:	2014 W 102ND ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-2027
Country	:	US
Telephone Number	:	773-636-3418
Fax Number	:

Provider Business Practice Location Address
First Line	:	2014 W 102ND ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-2027
Country	:	US
Telephone Number	:	773-636-3418
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	06/01/2015

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