MEDICARE: MS. ELIZABETH A. WALL R.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	133V00000X	Registered Dietitian		IL

General Provider Information

NPI Number	:	1740200732
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ELIZABETH A. WALL R.D.

Provider Business Mailing Address
First Line	:	911 SHERIDAN RD
Second Line	:
City	:	EVANSTON
State	:	IL
Zip	:	60202-5432
Country	:	US
Telephone Number	:	773-834-2876
Fax Number	:	773-702-6972

Provider Business Practice Location Address
First Line	:	5847 S. MARYLAND AVE
Second Line	:	MC 4080
City	:	CHICAGO
State	:	IL
Zip	:	60637
Country	:	US
Telephone Number	:	773-834-2876
Fax Number	:	773-702-6972

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

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	07/08/2007

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