MEDICARE: DR. DEEPA BALSARA PHARM.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	183500000X	Pharmacist		IL

General Provider Information

NPI Number	:	1174647556
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DEEPA BALSARA PHARM.D.

Provider Business Mailing Address
First Line	:	950 W MONROE ST
Second Line	:	UNIT 813
City	:	CHICAGO
State	:	IL
Zip	:	60607-2788
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	255 E GRAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-3315
Country	:	US
Telephone Number	:	312-279-1309
Fax Number	:

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

Provider Enumeration Date	:	03/19/2007
Last Update Date	:	07/08/2007

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