MEDICARE: MR. VIKRAM PANCHOLI OTR/L

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	225X00000X	Occupational Therapist	056007227	IL

General Provider Information

NPI Number	:	1306161393
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. VIKRAM PANCHOLI OTR/L

Provider Business Mailing Address
First Line	:	660 W WAYMAN ST
Second Line	:	#304
City	:	CHICAGO
State	:	IL
Zip	:	60661-1296
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	660 W WAYMAN ST
Second Line	:	#304
City	:	CHICAGO
State	:	IL
Zip	:	60661-1296
Country	:	US
Telephone Number	:	313-283-8194
Fax Number	:

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

Provider Enumeration Date	:	04/01/2010
Last Update Date	:	04/01/2010

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