MEDICARE: JOANNA TKACZ AGENT

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	171W00000X	Contractor	ACC/HEALTH--11/09/06	IL
2	171W00000X	Contractor	ACC/HEALTH	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	17	OTHER	IL	OTHER SERVICE PROVIDERS

General Provider Information

NPI Number	:	1053585398
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOANNA TKACZ AGENT

Provider Business Mailing Address
First Line	:	5304 S MELVINA AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60638-2618
Country	:	US
Telephone Number	:	773-581-1698
Fax Number	:

Provider Business Practice Location Address
First Line	:	5304 S MELVINA AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60638-2618
Country	:	US
Telephone Number	:	773-581-1698
Fax Number	:

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

Provider Enumeration Date	:	04/17/2008
Last Update Date	:	04/17/2008

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Directions to “ JOANNA TKACZ AGENT” Practice Location

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