MEDICARE: DR. TED J JAGIELO 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	:	1437290905
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TED J JAGIELO MD

Provider Business Mailing Address
First Line	:	7447 W TALCOTT AVE STE 521
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60631-3716
Country	:	US
Telephone Number	:	773-763-3300
Fax Number	:

Provider Business Practice Location Address
First Line	:	7447 W TALCOTT AVE STE 521
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60631-3716
Country	:	US
Telephone Number	:	773-763-3300
Fax Number	:

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

Provider Enumeration Date	:	02/09/2007
Last Update Date	:	07/08/2007

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