MEDICARE: BARBARA M CISLO MMS, PA-C

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	363A00000X	Physician Assistant		IL

General Provider Information

NPI Number	:	1942361217
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BARBARA M CISLO MMS, PA-C

Provider Business Mailing Address
First Line	:	5443 EDISON AVE
Second Line	:
City	:	OAK LAWN
State	:	IL
Zip	:	60453-2943
Country	:	US
Telephone Number	:	708-425-0420
Fax Number	:	773-834-8891

Provider Business Practice Location Address
First Line	:	5758 S MARYLAND AVE
Second Line	:	MC 9028
City	:	CHICAGO
State	:	IL
Zip	:	60637-1426
Country	:	US
Telephone Number	:	773-702-7573
Fax Number	:	773-834-8891

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

Provider Enumeration Date	:	12/12/2006
Last Update Date	:	07/08/2007

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