MEDICARE: DR. JOSE RAFAEL DEURRUTIA 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	207Q00000X	Family Medicine Physician	036.077752	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	4622394	OTHER		BLUE CROSS

General Provider Information

NPI Number	:	1831136647
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOSE RAFAEL DEURRUTIA M.D.

Provider Business Mailing Address
First Line	:	3700 W 26TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60623-3824
Country	:	US
Telephone Number	:	773-542-5203
Fax Number	:

Provider Business Practice Location Address
First Line	:	3700 W 26TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60623-3824
Country	:	US
Telephone Number	:	773-542-5203
Fax Number	:

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

Provider Enumeration Date	:	06/01/2006
Last Update Date	:	11/10/2020

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