MEDICARE: JAMES EDWARD GONZALES CST/CSFA

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	246ZC0007X	Surgical Assistant

General Provider Information

NPI Number	:	1487928875
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES EDWARD GONZALES CST/CSFA

Provider Business Mailing Address
First Line	:	1515 S PRAIRIE AVE
Second Line	:	1302
City	:	CHICAGO
State	:	IL
Zip	:	60605-3043
Country	:	US
Telephone Number	:	708-705-3772
Fax Number	:

Provider Business Practice Location Address
First Line	:	1515 S PRAIRIE AVE
Second Line	:	1302
City	:	CHICAGO
State	:	IL
Zip	:	60605-3043
Country	:	US
Telephone Number	:	708-705-3772
Fax Number	:

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

Provider Enumeration Date	:	03/01/2012
Last Update Date	:	03/01/2012

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