MEDICARE: DR. KRYSTYNA HELENA BERRY 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	207W00000X	Ophthalmology Physician	036.049981	IL

General Provider Information

NPI Number	:	1417225210
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KRYSTYNA HELENA BERRY M.D.

Provider Business Mailing Address
First Line	:	1632 N WOLCOTT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-1322
Country	:	US
Telephone Number	:	775-227-5572
Fax Number	:	773-227-5572

Provider Business Practice Location Address
First Line	:	1632 N WOLCOTT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-1322
Country	:	US
Telephone Number	:	775-227-5572
Fax Number	:	773-227-5572

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

Provider Enumeration Date	:	12/07/2011
Last Update Date	:	12/07/2011

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