MEDICARE: DR. JONITH Y. BREADON M.D.

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		IL

General Provider Information

NPI Number	:	1457402109
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONITH Y. BREADON M.D.

Provider Business Mailing Address
First Line	:	1009 W FULTON MARKET
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607-1222
Country	:	US
Telephone Number	:	312-733-2492
Fax Number	:	312-733-2498

Provider Business Practice Location Address
First Line	:	1009 W FULTON MARKET
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607-1222
Country	:	US
Telephone Number	:	312-733-2492
Fax Number	:	312-733-2498

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

Provider Enumeration Date	:	01/16/2007
Last Update Date	:	07/08/2007

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