MEDICARE: JOHN G LATALL MD 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	261QM2500X	Medical Specialty Clinic/Center	036-084430	IL
2	207KA0200X	Allergy Physician

General Provider Information

NPI Number	:	1134485055
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHN G LATALL MD SC

Provider Business Mailing Address
First Line	:	2073 N CLYBOURN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-4003
Country	:	US
Telephone Number	:	773-665-4016
Fax Number	:	773-665-0403

Provider Business Practice Location Address
First Line	:	2073 N CLYBOURN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-4003
Country	:	US
Telephone Number	:	773-665-4016
Fax Number	:	773-360-6200

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOHN G LATALL
Credential	:	M.D.
Telephone Number	:	773-665-4016

Provider Enumeration Date	:	04/04/2012
Last Update Date	:	10/05/2022

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