MEDICARE: DR. MARSHA JANE BRAZLEY M.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	208000000X	Pediatrics Physician		IL

General Provider Information

NPI Number	:	1356408421
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARSHA JANE BRAZLEY M.D.

Provider Business Mailing Address
First Line	:	443 E 31ST ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-4051
Country	:	US
Telephone Number	:	312-225-2055
Fax Number	:	312-435-1450

Provider Business Practice Location Address
First Line	:	8747 S STATE ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60619-6608
Country	:	US
Telephone Number	:	312-225-2055
Fax Number	:	312-435-1450

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

Provider Enumeration Date	:	01/02/2007
Last Update Date	:	07/08/2007

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