MEDICARE: CHICAGO SPORTS MEDICINE LLC

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

General Provider Information

NPI Number	:	1093107989
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHICAGO SPORTS MEDICINE LLC

Provider Business Mailing Address
First Line	:	1130 W GRANVILLE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-2013
Country	:	US
Telephone Number	:	773-784-6682
Fax Number	:	773-784-5735

Provider Business Practice Location Address
First Line	:	1130 W GRANVILLE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-2013
Country	:	US
Telephone Number	:	773-784-6682
Fax Number	:	773-784-5735

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ANDREW GARD I
Credential	:	DC
Telephone Number	:	773-784-6682

Provider Enumeration Date	:	03/02/2015
Last Update Date	:	03/02/2015

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Directions to “CHICAGO SPORTS MEDICINE LLC ” Practice Location

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