MEDICARE: DR. MICHAEL R PIETRUS PSY.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	103T00000X	Psychologist	071.008203	IL

General Provider Information

NPI Number	:	1295018075
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL R PIETRUS PSY.D

Provider Business Mailing Address
First Line	:	410 S MICHIGAN AVE
Second Line	:	SUITE 707
City	:	CHICAGO
State	:	IL
Zip	:	60605-1308
Country	:	US
Telephone Number	:	312-869-9401
Fax Number	:

Provider Business Practice Location Address
First Line	:	410 S MICHIGAN AVE
Second Line	:	SUITE 707
City	:	CHICAGO
State	:	IL
Zip	:	60605-1308
Country	:	US
Telephone Number	:	312-869-9401
Fax Number	:

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

Provider Enumeration Date	:	09/27/2011
Last Update Date	:	12/22/2011

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