MEDICARE: MR. MAHENDRA KHATAU

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	183500000X	Pharmacist		IL

General Provider Information

NPI Number	:	1033256524
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MAHENDRA KHATAU

Provider Business Mailing Address
First Line	:	3179 W MADISON ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612
Country	:	US
Telephone Number	:	630-789-1722
Fax Number	:

Provider Business Practice Location Address
First Line	:	3179 W MADISON ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-1809
Country	:	US
Telephone Number	:	773-722-2626
Fax Number	:	773-722-2662

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

Provider Enumeration Date	:	01/31/2007
Last Update Date	:	07/08/2007

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