MEDICARE: LARRY EDWARD BALDWIN PH.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	103TC0700X	Clinical Psychologist		IL

General Provider Information

NPI Number	:	1568542595
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARRY EDWARD BALDWIN PH.D

Provider Business Mailing Address
First Line	:	418 15TH ST
Second Line	:
City	:	WILMETTE
State	:	IL
Zip	:	60091-2514
Country	:	US
Telephone Number	:	847-251-6436
Fax Number	:	847-251-6034

Provider Business Practice Location Address
First Line	:	1945 W WILSON AVE
Second Line	:	FOURTH FLOOR
City	:	CHICAGO
State	:	IL
Zip	:	60640-5255
Country	:	US
Telephone Number	:	773-769-4600
Fax Number	:	773-769-0042

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

Provider Enumeration Date	:	10/16/2006
Last Update Date	:	07/08/2007

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