MEDICARE: RODOLFO CHOUSSAL-GONZALEZ MD

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	207R00000X	Internal Medicine Physician	34890	MT
2	207RI0200X	Infectious Disease Physician	34890	MT
3	208M00000X	Hospitalist Physician	34890	MT
4	207RI0200X	Infectious Disease Physician	036157658	IL

General Provider Information

NPI Number	:	1689945792
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RODOLFO CHOUSSAL-GONZALEZ MD

Provider Business Mailing Address
First Line	:	2740 W FOSTER AVE STE 410
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-3532
Country	:	US
Telephone Number	:	773-907-3400
Fax Number	:	773-907-0341

Provider Business Practice Location Address
First Line	:	2740 W FOSTER AVE STE 410
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-3532
Country	:	US
Telephone Number	:	773-907-3400
Fax Number	:	773-907-0341

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

Provider Enumeration Date	:	01/20/2012
Last Update Date	:	08/26/2021

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