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NPI Code Detail

MEDICARE: MR. JUSTIN I WASHINGTON RD

MEDICARE: MR. JUSTIN I WASHINGTON RD
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
1133V00000XRegistered DietitianIL

General Provider Information

NPI Number : 1336105618
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. JUSTIN I WASHINGTON RD
Provider Business Mailing Address
First Line : 9540 S INDIANA AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60628-1410
Country : US
Telephone Number : 312-572-1231
Fax Number : 312-572-1230
Provider Business Practice Location Address
First Line : 500 E 51ST ST
Second Line : PROVIDENT HOSPITAL
City : CHICAGO
State : IL
Zip : 60615-2400
Country : US
Telephone Number : 312-572-1231
Fax Number : 312-572-1230
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/25/2006
Last Update Date : 07/08/2007

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