MEDICARE: 63RD ADVANCED HEALTH CLINIC INC

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	207QA0000X	Adolescent Medicine (Family Medicine) Physician

General Provider Information

NPI Number	:	1548492234
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	63RD ADVANCED HEALTH CLINIC INC

Provider Business Mailing Address
First Line	:	1249 W 63RD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60636-1947
Country	:	US
Telephone Number	:	847-904-7500
Fax Number	:	847-904-7502

Provider Business Practice Location Address
First Line	:	1249 W 63RD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60636-1947
Country	:	US
Telephone Number	:	847-904-7500
Fax Number	:	847-904-7502

Authorized Official
Title or Position	:	OWNER
Name	:	ALESIA CHAIKA
Credential	:
Telephone Number	:	847-904-7500

Provider Enumeration Date	:	08/14/2009
Last Update Date	:	08/14/2009

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