MEDICARE: DALE ANTHONY CHARLETTA 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	2085R0202X	Diagnostic Radiology Physician	036072329	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	1615479	OTHER	BCBBS
2	300127675	OTHER	RR MC
3	CN0576	OTHER	GROUP #
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164497731
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DALE ANTHONY CHARLETTA MD

Provider Business Mailing Address
First Line	:	4800 S GREENWOOD AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60615-1914
Country	:	US
Telephone Number	:	312-315-8046
Fax Number	:	312-284-4800

Provider Business Practice Location Address
First Line	:	4800 S GREENWOOD AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60615-1914
Country	:	US
Telephone Number	:	312-315-8046
Fax Number	:	312-284-4800

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

Provider Enumeration Date	:	02/17/2006
Last Update Date	:	10/21/2016

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