MEDICARE: AURORA HEALTHCARE INC

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	036.059705	IL

General Provider Information

NPI Number	:	1114321353
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AURORA HEALTHCARE INC

Provider Business Mailing Address
First Line	:	1502 W CHICAGO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60642-5236
Country	:	US
Telephone Number	:	773-672-2561
Fax Number	:	773-672-2560

Provider Business Practice Location Address
First Line	:	1502 W CHICAGO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60642-5236
Country	:	US
Telephone Number	:	773-672-2561
Fax Number	:	773-672-2560

Authorized Official
Title or Position	:	OWNER
Name	:	GENNADII KARANDIEIEV
Credential	:
Telephone Number	:	773-672-2561

Provider Enumeration Date	:	10/17/2014
Last Update Date	:	10/17/2014

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