MEDICARE: NORTHWEST CHICAGO MEDICAL LTD

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	261QA1903X	Ambulatory Surgical Clinic/Center
2	332B00000X	Durable Medical Equipment & Medical Supplies	203.000961	IL

General Provider Information

NPI Number	:	1063693323
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHWEST CHICAGO MEDICAL LTD

Provider Business Mailing Address
First Line	:	2651 N LARAMIE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639-1613
Country	:	US
Telephone Number	:	773-745-0391
Fax Number	:	773-745-3506

Provider Business Practice Location Address
First Line	:	2651 N LARAMIE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639-1613
Country	:	US
Telephone Number	:	773-745-0391
Fax Number	:	773-745-3506

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. JACK CHODZEN
Credential	:	PT
Telephone Number	:	773-745-0391

Provider Enumeration Date	:	11/15/2007
Last Update Date	:	11/12/2014

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