MEDICARE: DR. CHAD THOMAS MILLSAP O.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	152W00000X	Optometrist	046.009390	IL

General Provider Information

NPI Number	:	1477584605
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHAD THOMAS MILLSAP O.D.

Provider Business Mailing Address
First Line	:	2170 N LINCOLN AVE
Second Line	:	#1
City	:	CHICAGO
State	:	IL
Zip	:	60614-4511
Country	:	US
Telephone Number	:	773-327-8519
Fax Number	:	773-327-3015

Provider Business Practice Location Address
First Line	:	1515 N MILWAUKEE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-2009
Country	:	US
Telephone Number	:	773-772-2424
Fax Number	:	773-772-2828

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

Provider Enumeration Date	:	07/05/2006
Last Update Date	:	09/10/2008

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