MEDICARE: MR. JOSE MARIO GONZALEZ

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	183500000X	Pharmacist	051.039540	IL

General Provider Information

NPI Number	:	1952623258
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOSE MARIO GONZALEZ

Provider Business Mailing Address
First Line	:	1350 W FULLERTON AVE
Second Line	:	UNIT 404
City	:	CHICAGO
State	:	IL
Zip	:	60614-2198
Country	:	US
Telephone Number	:	773-244-3361
Fax Number	:

Provider Business Practice Location Address
First Line	:	5050 S KEDZIE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60632-3009
Country	:	US
Telephone Number	:	773-476-6323
Fax Number	:

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

Provider Enumeration Date	:	02/28/2010
Last Update Date	:	02/28/2010

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