MEDICARE: DR. YUKHOL LERTSBURAPA MD

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	173000000X	Legal Medicine		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	31600582	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1043200975
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. YUKHOL LERTSBURAPA MD

Provider Business Mailing Address
First Line	:	PO BOX 8043
Second Line	:
City	:	WOODRIDGE
State	:	IL
Zip	:	60517-8043
Country	:	US
Telephone Number	:	773-486-3535
Fax Number	:	630-983-8803

Provider Business Practice Location Address
First Line	:	2222 W DIVISION ST
Second Line	:	SUITE 260
City	:	CHICAGO
State	:	IL
Zip	:	60622-2717
Country	:	US
Telephone Number	:	773-486-3535
Fax Number	:	630-983-8803

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

Provider Enumeration Date	:	10/23/2005
Last Update Date	:	07/08/2007

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