MEDICARE: HARVEY DEBOFSKY MD, LTD

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	036035346	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01604576	OTHER	IL	BC/BS PROVIDER #

General Provider Information

NPI Number	:	1053338798
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HARVEY DEBOFSKY MD, LTD

Provider Business Mailing Address
First Line	:	2315 E 93RD ST
Second Line	:	SUITE 200
City	:	CHICAGO
State	:	IL
Zip	:	60617-3936
Country	:	US
Telephone Number	:	773-734-3970
Fax Number	:	773-734-6832

Provider Business Practice Location Address
First Line	:	2315 E 93RD ST
Second Line	:	SUITE 200
City	:	CHICAGO
State	:	IL
Zip	:	60617-3936
Country	:	US
Telephone Number	:	773-734-3970
Fax Number	:	773-734-6832

Authorized Official
Title or Position	:	BILLING COORDINATOR
Name	:	LYNNETTE MCROY
Credential	:
Telephone Number	:	773-767-3822

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	03/24/2010

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