MEDICARE: DR. NEDA ZERGOLLERN TKALCEVIC MD

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	207N00000X	Dermatology Physician	036050674	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	04900707	OTHER		BLUE SHIELD

General Provider Information

NPI Number	:	1164494183
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NEDA ZERGOLLERN TKALCEVIC MD

Provider Business Mailing Address
First Line	:	1801 MILLBURNE RD
Second Line	:
City	:	LAKE FOREST
State	:	IL
Zip	:	60045
Country	:	US
Telephone Number	:	847-295-7620
Fax Number	:	847-295-7619

Provider Business Practice Location Address
First Line	:	30 TOWER CT STE C
Second Line	:	GREENLEAF CENTER
City	:	GURNEE
State	:	IL
Zip	:	60031-3322
Country	:	US
Telephone Number	:	847-559-0715
Fax Number	:	847-599-0766

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

Provider Enumeration Date	:	02/03/2006
Last Update Date	:	11/12/2009

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