Provider Demographics
NPI:1568630549
Name:SOUTH BERWYN SCHOOL DIST 100
Entity Type:Organization
Organization Name:SOUTH BERWYN SCHOOL DIST 100
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:BAGUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-795-2300
Mailing Address - Street 1:3401 GUNDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3771
Mailing Address - Country:US
Mailing Address - Phone:708-795-2300
Mailing Address - Fax:
Practice Address - Street 1:3401 GUNDERSON AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3771
Practice Address - Country:US
Practice Address - Phone:708-795-2300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid