MEDICARE: RENE C VELAZCO 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	207Q00000X	Family Medicine Physician		IL

General Provider Information

NPI Number	:	1245257955
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RENE C VELAZCO MD

Provider Business Mailing Address
First Line	:	4215 RUTGERS LN
Second Line	:
City	:	NORTHBROOK
State	:	IL
Zip	:	60062-2913
Country	:	US
Telephone Number	:	847-205-0561
Fax Number	:	773-334-4931

Provider Business Practice Location Address
First Line	:	5137 N BROADWAY ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-3009
Country	:	US
Telephone Number	:	773-334-3767
Fax Number	:	773-334-4931

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

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	07/08/2007

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