MEDICARE: CHICAGO MONTICELLO MEDICAL CTR

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	332900000X	Non-Pharmacy Dispensing Site		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1478723	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER
2	1478723	OTHER		OTHER ID NUMBER

General Provider Information

NPI Number	:	1447265053
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHICAGO MONTICELLO MEDICAL CTR

Provider Business Mailing Address
First Line	:	3623 W CHICAGO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60651-3934
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3623 W CHICAGO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60651-3934
Country	:	US
Telephone Number	:	773-722-6171
Fax Number	:	773-722-7913

Authorized Official
Title or Position	:	MD
Name	:	MICHAEL EARLEY
Credential	:
Telephone Number	:	773-722-6171

Provider Enumeration Date	:	07/30/2006
Last Update Date	:	11/19/2007

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Directions to “CHICAGO MONTICELLO MEDICAL CTR ” Practice Location

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