MEDICARE: SAMUEL CUBE FERNANDO MD

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	207R00000X	Internal Medicine Physician		IL

General Provider Information

NPI Number	:	1023124930
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL CUBE FERNANDO MD

Provider Business Mailing Address
First Line	:	8535 W 79TH ST
Second Line	:
City	:	JUSTICE
State	:	IL
Zip	:	60458-2281
Country	:	US
Telephone Number	:	708-458-7474
Fax Number	:	708-458-7473

Provider Business Practice Location Address
First Line	:	8535 W 79TH ST
Second Line	:
City	:	JUSTICE
State	:	IL
Zip	:	60458-2281
Country	:	US
Telephone Number	:	708-458-7474
Fax Number	:	708-458-7479

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

Provider Enumeration Date	:	08/22/2006
Last Update Date	:	07/08/2007

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