MEDICARE: MRS. DANA ROSE CONLAN

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	174400000X	Specialist	057.003001	IL

General Provider Information

NPI Number	:	1427379924
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DANA ROSE CONLAN

Provider Business Mailing Address
First Line	:	1816 S RACINE AVE # 2R
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-3214
Country	:	US
Telephone Number	:	203-583-0030
Fax Number	:

Provider Business Practice Location Address
First Line	:	1816 S RACINE AVE #2R
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608
Country	:	US
Telephone Number	:	203-583-0030
Fax Number	:

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

Provider Enumeration Date	:	06/18/2010
Last Update Date	:	06/18/2010

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