MEDICARE: MEDICI HEALTHCARE PROVIDERS S.C

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	261Q00000X	Clinic/Center
2	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1336267467
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICI HEALTHCARE PROVIDERS S.C

Provider Business Mailing Address
First Line	:	310 N LOOMIS ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607-1147
Country	:	US
Telephone Number	:	312-733-2273
Fax Number	:	312-733-7225

Provider Business Practice Location Address
First Line	:	2381 N MILWAUKEE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-2924
Country	:	US
Telephone Number	:	773-227-2687
Fax Number	:	312-288-0164

Authorized Official
Title or Position	:	CEO
Name	:	DR. MAURICIO CONSALTER
Credential	:	MD
Telephone Number	:	312-550-2148

Provider Enumeration Date	:	03/27/2007
Last Update Date	:	12/22/2021

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