MEDICARE: AXIS MEDICAL MANAGEMENT GOUP SC

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	111NR0400X	Rehabilitation Chiropractor	042.618397038.010225	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1634898	OTHER	IL	BLUE CROSS BLUE SHIELD ID

General Provider Information

NPI Number	:	1932221397
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AXIS MEDICAL MANAGEMENT GOUP SC

Provider Business Mailing Address
First Line	:	4111 W 26TH ST
Second Line	:	SUITE 110
City	:	CHICAGO
State	:	IL
Zip	:	60623-4313
Country	:	US
Telephone Number	:	773-542-1111
Fax Number	:	773-542-7100

Provider Business Practice Location Address
First Line	:	4111 W 26TH ST
Second Line	:	SUITE 110
City	:	CHICAGO
State	:	IL
Zip	:	60623-4313
Country	:	US
Telephone Number	:	773-542-1111
Fax Number	:	773-542-7100

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	JAN STRUWE
Credential	:
Telephone Number	:	773-542-1111

Provider Enumeration Date	:	04/05/2007
Last Update Date	:	04/25/2008

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Directions to “AXIS MEDICAL MANAGEMENT GOUP SC ” Practice Location

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