=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952618316
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELJUN L GOMEZ NP-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2010
-----------------------------------------------------
Last Update Date | 09/07/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2266 N LINCOLN AVE LOWR LEVEL
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60614-7600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-883-3953
-----------------------------------------------------
Fax | 773-883-3649
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1040 W ADAMS ST UNIT 346
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60607-3087
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-744-2935
-----------------------------------------------------
Fax | 773-883-3649
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 209.008312
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------