MEDICARE: DR. AVTAR K RAZDAN I 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	2080A0000X	Pediatric Adolescent Medicine Physician	036048822	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	04607499	OTHER	IL	BLUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376536615
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AVTAR K RAZDAN I M.D.

Provider Business Mailing Address
First Line	:	475 BROWN BLVD
Second Line	:	SUITE 102
City	:	BOURBONNAIS
State	:	IL
Zip	:	60914-2325
Country	:	US
Telephone Number	:	815-939-0003
Fax Number	:	815-935-4908

Provider Business Practice Location Address
First Line	:	475 BROWN BLVD
Second Line	:	SUITE 102
City	:	BOURBONNAIS
State	:	IL
Zip	:	60914-2325
Country	:	US
Telephone Number	:	815-939-0003
Fax Number	:	815-935-4908

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

Provider Enumeration Date	:	08/23/2005
Last Update Date	:	09/28/2012

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