=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538335278
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. PATRICK C CROSS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2008
-----------------------------------------------------
Last Update Date | 05/02/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5915 W MONTROSE AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60634-1626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-685-7121
-----------------------------------------------------
Fax | 773-685-7143
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5915 W MONTROSE AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60634-1626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-685-7121
-----------------------------------------------------
Fax | 773-685-7143
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019023286
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------