MEDICARE: ELY ROBERT TANDETER

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	207R00000X	Internal Medicine Physician	036063792	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457306953
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELY ROBERT TANDETER

Provider Business Mailing Address
First Line	:	2837 N MILWAUKEE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-7403
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2837 N MILWAUKEE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-7403
Country	:	US
Telephone Number	:	773-235-6266
Fax Number	:

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

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	07/26/2013

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