MEDICARE: DR. ANDREE C. DE BUSTROS 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	207RE0101X	Endocrinology, Diabetes & Metabolism Physician	036081805	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	IL3323019	OTHER	IL	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	326170152	OTHER	IL	TAX ID
4	01621253	OTHER	IL	BLUE SHIELD NUMBER

General Provider Information

NPI Number	:	1932108545
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANDREE C. DE BUSTROS M.D.

Provider Business Mailing Address
First Line	:	5525 S PULASKI RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60629-4400
Country	:	US
Telephone Number	:	312-567-7500
Fax Number	:

Provider Business Practice Location Address
First Line	:	5525 S PULASKI RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60629
Country	:	US
Telephone Number	:	312-567-7500
Fax Number	:

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

Provider Enumeration Date	:	07/15/2005
Last Update Date	:	05/16/2018

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