MEDICARE: DR. JEFFREY BENJAMIN WYGODNY 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	207L00000X	Anesthesiology Physician	036090678	IL

General Provider Information

NPI Number	:	1437263076
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY BENJAMIN WYGODNY M,D,

Provider Business Mailing Address
First Line	:	2128 W CORTEZ ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-3601
Country	:	US
Telephone Number	:	773-593-4607
Fax Number	:

Provider Business Practice Location Address
First Line	:	2128 W CORTEZ ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-3601
Country	:	US
Telephone Number	:	773-593-4607
Fax Number	:

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

Provider Enumeration Date	:	08/19/2006
Last Update Date	:	05/20/2008

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