MEDICARE: MARANATHA FAMILY MEDICINE

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	036063544	IL

General Provider Information

NPI Number	:	1487898417
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARANATHA FAMILY MEDICINE

Provider Business Mailing Address
First Line	:	550 N MIDLOTHIAN RD
Second Line	:
City	:	MUNDELEIN
State	:	IL
Zip	:	60060-1613
Country	:	US
Telephone Number	:	847-949-8474
Fax Number	:	847-949-4825

Provider Business Practice Location Address
First Line	:	550 N MIDLOTHIAN RD
Second Line	:
City	:	MUNDELEIN
State	:	IL
Zip	:	60060-1613
Country	:	US
Telephone Number	:	847-949-8474
Fax Number	:	847-949-4825

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CHESTER GREGORY LASKOWSKI
Credential	:	M.D.
Telephone Number	:	847-949-8474

Provider Enumeration Date	:	04/21/2009
Last Update Date	:	04/21/2009

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