MEDICARE: ANDREA LUISA PEACH DPM

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	213E00000X	Podiatrist	016005323	IL
2	213E00000X	Podiatrist	PO3449	FL

General Provider Information

NPI Number	:	1083875256
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA LUISA PEACH DPM

Provider Business Mailing Address
First Line	:	1229 N NORTH BRANCH ST
Second Line	:	SUITE 210
City	:	CHICAGO
State	:	IL
Zip	:	60642-2473
Country	:	US
Telephone Number	:	312-939-5090
Fax Number	:	312-640-4496

Provider Business Practice Location Address
First Line	:	1229 N NORTH BRANCH ST
Second Line	:	SUITE 210
City	:	CHICAGO
State	:	IL
Zip	:	60642-2473
Country	:	US
Telephone Number	:	312-939-5090
Fax Number	:	312-640-4496

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

Provider Enumeration Date	:	06/20/2008
Last Update Date	:	01/11/2011

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