MEDICARE: DR. JOHN EDWARD MUNDT 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0051648579	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1710998596
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN EDWARD MUNDT PH.D.

Provider Business Mailing Address
First Line	:	1523 WILLIAM ST
Second Line	:
City	:	RIVER FOREST
State	:	IL
Zip	:	60305-1138
Country	:	US
Telephone Number	:	312-608-0668
Fax Number	:

Provider Business Practice Location Address
First Line	:	1523 WILLIAM ST
Second Line	:
City	:	RIVER FOREST
State	:	IL
Zip	:	60305-1138
Country	:	US
Telephone Number	:	312-608-0668
Fax Number	:

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

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

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