MEDICARE: CASTILLO-JUAT MEDICAL GROUP SC

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	207V00000X	Obstetrics & Gynecology Physician		IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	382220	OTHER	IL	MEDICARE GROUP NUMBER

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	21604249	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1083886279
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CASTILLO-JUAT MEDICAL GROUP SC

Provider Business Mailing Address
First Line	:	3019 N LINCOLN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-4207
Country	:	US
Telephone Number	:	773-528-8372
Fax Number	:	773-528-8372

Provider Business Practice Location Address
First Line	:	3019 N LINCOLN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-4207
Country	:	US
Telephone Number	:	773-528-8372
Fax Number	:	773-528-8372

Authorized Official
Title or Position	:	MD/PRESIDENT
Name	:	DR. ANNABELLA CASTILLO-JUAT
Credential	:	MD
Telephone Number	:	773-528-8372

Provider Enumeration Date	:	03/27/2008
Last Update Date	:	04/16/2008

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