MEDICARE: BERNADETA LEEGAN WIBISONO M.D.

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	208000000X	Pediatrics Physician	125055427	IL

General Provider Information

NPI Number	:	1003143504
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BERNADETA LEEGAN WIBISONO M.D.

Provider Business Mailing Address
First Line	:	2951 S KING DR APT 1004
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-3359
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2951 S KING DR APT 1004
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-3359
Country	:	US
Telephone Number	:	312-351-1346
Fax Number	:

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

Provider Enumeration Date	:	11/04/2009
Last Update Date	:	11/04/2009

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