MEDICARE: MARQUE MEDICOS KEDZIE, LLC

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	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1194985747
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARQUE MEDICOS KEDZIE, LLC

Provider Business Mailing Address
First Line	:	4176 W MONTROSE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-2161
Country	:	US
Telephone Number	:	773-283-3131
Fax Number	:	773-283-3610

Provider Business Practice Location Address
First Line	:	5825 S KEDZIE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60629-3212
Country	:	US
Telephone Number	:	773-283-3131
Fax Number	:	773-283-3610

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. DERRICK D. WALLERY
Credential	:	D.C.
Telephone Number	:	773-283-3131

Provider Enumeration Date	:	06/16/2008
Last Update Date	:	06/16/2008

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