MEDICARE: GOMEZ CHARLESTON 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	207R00000X	Internal Medicine Physician		IL

General Provider Information

NPI Number	:	1124021795
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GOMEZ CHARLESTON MD

Provider Business Mailing Address
First Line	:	9000 S STONY ISLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60617-3508
Country	:	US
Telephone Number	:	773-731-0670
Fax Number	:

Provider Business Practice Location Address
First Line	:	9000 S STONY ISLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60617-3508
Country	:	US
Telephone Number	:	773-731-0670
Fax Number	:

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

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	07/08/2007

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