MEDICARE: KELLY C ESPARZA AU.D.

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	231H00000X	Audiologist	147001320	IL

General Provider Information

NPI Number	:	1083942213
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY C ESPARZA AU.D.

Provider Business Mailing Address
First Line	:	2440 BUDD ST
Second Line	:
City	:	RIVER GROVE
State	:	IL
Zip	:	60171-1735
Country	:	US
Telephone Number	:	312-213-3075
Fax Number	:

Provider Business Practice Location Address
First Line	:	5835 S COTTAGE GROVE AVE
Second Line	:	DCAM 4754
City	:	CHICAGO
State	:	IL
Zip	:	60637-1416
Country	:	US
Telephone Number	:	773-834-7102
Fax Number	:

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

Provider Enumeration Date	:	11/30/2009
Last Update Date	:	11/30/2009

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