MEDICARE: RENUKA N DESAI 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	36-063209	IL

General Provider Information

NPI Number	:	1699762328
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RENUKA N DESAI M.D.

Provider Business Mailing Address
First Line	:	45 TOWER CT
Second Line	:	SUITE C
City	:	GURNEE
State	:	IL
Zip	:	60031-3376
Country	:	US
Telephone Number	:	847-623-3200
Fax Number	:	847-623-9168

Provider Business Practice Location Address
First Line	:	2031 E GRAND AVE
Second Line	:
City	:	LINDENHURST
State	:	IL
Zip	:	60046-9041
Country	:	US
Telephone Number	:	847-356-5575
Fax Number	:	847-356-1792

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

Provider Enumeration Date	:	09/27/2005
Last Update Date	:	07/08/2007

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