=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710121512
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD JOHN ZALOUDEK M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2009
-----------------------------------------------------
Last Update Date | 04/23/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1236 N MAPLE AVE APT. 1
-----------------------------------------------------
City | LA GRANGE PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60526-1430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-597-9084
-----------------------------------------------------
Fax | 708-579-9345
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1236 N MAPLE AVE APT. 1
-----------------------------------------------------
City | LA GRANGE PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60526-1430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-597-9084
-----------------------------------------------------
Fax | 708-579-9345
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 036.053727
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------