MEDICARE: JOHN R DEFOREST D.O. S.C.

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	207Q00000X	Family Medicine Physician	336051704	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	080154175	OTHER	IL	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	9925692	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1144241407
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHN R DEFOREST D.O. S.C.

Provider Business Mailing Address
First Line	:	715 S DIXIE HWY
Second Line	:
City	:	BEECHER
State	:	IL
Zip	:	60401-3668
Country	:	US
Telephone Number	:	708-946-9330
Fax Number	:	708-946-2471

Provider Business Practice Location Address
First Line	:	715 S DIXIE HWY
Second Line	:
City	:	BEECHER
State	:	IL
Zip	:	60401-3668
Country	:	US
Telephone Number	:	708-946-9330
Fax Number	:	708-946-2471

Authorized Official
Title or Position	:	ACCT REP.
Name	:	KAREN RUCKMAN
Credential	:
Telephone Number	:	708-946-3990

Provider Enumeration Date	:	07/22/2006
Last Update Date	:	12/10/2014

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