MEDICARE: MIA BETH DEROIN D.O.

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	222Q00000X	Developmental Therapist		IL

General Provider Information

NPI Number	:	1306254271
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIA BETH DEROIN D.O.

Provider Business Mailing Address
First Line	:	320 W OAKDALE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-6419
Country	:	US
Telephone Number	:	773-871-5926
Fax Number	:

Provider Business Practice Location Address
First Line	:	4412 N OAK PARK AVE
Second Line	:
City	:	HARWOOD HEIGHTS
State	:	IL
Zip	:	60706-4836
Country	:	US
Telephone Number	:	630-673-9499
Fax Number	:

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

Provider Enumeration Date	:	07/23/2014
Last Update Date	:	07/23/2014

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