MEDICARE: KEDZIE MEDICAL 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	:	1558593947
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEDZIE MEDICAL CLINIC INC

Provider Business Mailing Address
First Line	:	262 N KEDZIE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-1869
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	262 N KEDZIE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-1869
Country	:	US
Telephone Number	:	847-904-7500
Fax Number	:

Authorized Official
Title or Position	:	CMM
Name	:	GOHAR AKOPYAN
Credential	:
Telephone Number	:	847-904-7500

Provider Enumeration Date	:	08/18/2009
Last Update Date	:	08/18/2009

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