MEDICARE: OTILIO MELERO MDSC

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	207Q00000X	Family Medicine Physician	036069929	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1635894	OTHER	IL	BCBS OF IL

General Provider Information

NPI Number	:	1063687804
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OTILIO MELERO MDSC

Provider Business Mailing Address
First Line	:	5430 S KEDZIE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60632-2620
Country	:	US
Telephone Number	:	773-471-2411
Fax Number	:	773-471-9703

Provider Business Practice Location Address
First Line	:	5430 S KEDZIE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60632-2620
Country	:	US
Telephone Number	:	773-471-2411
Fax Number	:	773-471-9703

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. OTILIO N MELERO
Credential	:	MD
Telephone Number	:	773-471-2411

Provider Enumeration Date	:	04/23/2008
Last Update Date	:	01/27/2012

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