MEDICARE: DR. LARYSA MYKYTIUK 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	208000000X	Pediatrics Physician		IL

General Provider Information

NPI Number	:	1558418475
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARYSA MYKYTIUK M.D.

Provider Business Mailing Address
First Line	:	2204 W WALTON ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-4815
Country	:	US
Telephone Number	:	773-276-9391
Fax Number	:

Provider Business Practice Location Address
First Line	:	5711 N LINCOLN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-4704
Country	:	US
Telephone Number	:	773-728-4784
Fax Number	:	773-728-4759

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

Provider Enumeration Date	:	01/04/2007
Last Update Date	:	07/08/2007

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