MEDICARE: DR. ROGELIO N LIBOON M.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	207Q00000X	Family Medicine Physician	036-047971	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	K50915	OTHER		MEDICARE PTAN

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

General Provider Information

NPI Number	:	1205834934
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROGELIO N LIBOON M.D.

Provider Business Mailing Address
First Line	:	1937 W 35TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60609-1206
Country	:	US
Telephone Number	:	773-523-8014
Fax Number	:	630-654-4362

Provider Business Practice Location Address
First Line	:	1937 W 35TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60609-1206
Country	:	US
Telephone Number	:	773-523-8014
Fax Number	:	630-654-4362

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

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	07/15/2014

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