MEDICARE: AVANT -GARDE MEDICNE SC

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	208100000X	Physical Medicine & Rehabilitation Physician	036-111103	IL

General Provider Information

NPI Number	:	1275918112
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AVANT -GARDE MEDICNE SC

Provider Business Mailing Address
First Line	:	1401 S CALIFORNIA AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-1858
Country	:	US
Telephone Number	:	773-522-2010
Fax Number	:

Provider Business Practice Location Address
First Line	:	215 W WASHINGTON ST APT 5006
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60606-3543
Country	:	US
Telephone Number	:	702-566-5343
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DEEPTHI S SAXENA
Credential	:	M.D.
Telephone Number	:	702-566-4343

Provider Enumeration Date	:	07/21/2015
Last Update Date	:	07/21/2015

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