MEDICARE: DR. JOEL N SLUTSKY 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	208800000X	Urology Physician		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4600208	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1063403665
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOEL N SLUTSKY MD

Provider Business Mailing Address
First Line	:	375 N WALL ST
Second Line	:	STE P530
City	:	KANKAKEE
State	:	IL
Zip	:	60901-3483
Country	:	US
Telephone Number	:	815-937-4006
Fax Number	:	815-937-3850

Provider Business Practice Location Address
First Line	:	375 N WALL ST
Second Line	:	STE P530
City	:	KANKAKEE
State	:	IL
Zip	:	60901-3483
Country	:	US
Telephone Number	:	815-937-4006
Fax Number	:	815-937-3850

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

Provider Enumeration Date	:	11/02/2005
Last Update Date	:	01/27/2008

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