MEDICARE: COLMED CLINIC LTD

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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1194380147
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLMED CLINIC LTD

Provider Business Mailing Address
First Line	:	3615 N ASHLAND AVE APT 1N
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-4742
Country	:	US
Telephone Number	:	773-770-6300
Fax Number	:	773-665-5007

Provider Business Practice Location Address
First Line	:	3615 N ASHLAND AVE APT 1N
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-4742
Country	:	US
Telephone Number	:	773-770-6300
Fax Number	:	773-665-5007

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	WAYNE MEYERS
Credential	:
Telephone Number	:	773-770-6300

Provider Enumeration Date	:	05/06/2019
Last Update Date	:	05/06/2019

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