MEDICARE: DEKALB CLINIC CHARTERED

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	101YM0800X	Mental Health Counselor
2	1041C0700X	Clinical Social Worker
3	163WW0000X	Wound Care Registered Nurse
4	207K00000X	Allergy & Immunology Physician
5	207N00000X	Dermatology Physician	036119759	IL
6	207RC0000X	Cardiovascular Disease Physician
7	207W00000X	Ophthalmology Physician	036120383	IL
8	208000000X	Pediatrics Physician
9	2084P0800X	Psychiatry Physician
10	208600000X	Surgery Physician
11	208800000X	Urology Physician
12	213ES0103X	Foot & Ankle Surgery Podiatrist	016-005282	IL
13	207RP1001X	Pulmonary Disease Physician		IL
14	133V00000X	Registered Dietitian		IL
15	207R00000X	Internal Medicine Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	663680	OTHER	IL	MEDICARE-GROUP ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	14D0415284	OTHER	IL	CLIA #
2	1421279	OTHER	IL	NABP
4	148547	OTHER	IL	MC INDEPENDENT LAB

General Provider Information

NPI Number	:	1447277140
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEKALB CLINIC CHARTERED

Provider Business Mailing Address
First Line	:	1850 GATEWAY DR
Second Line	:
City	:	SYCAMORE
State	:	IL
Zip	:	60178-3192
Country	:	US
Telephone Number	:	815-758-8671
Fax Number	:	815-758-5610

Provider Business Practice Location Address
First Line	:	1850 GATEWAY DR
Second Line	:
City	:	SYCAMORE
State	:	IL
Zip	:	60178-3192
Country	:	US
Telephone Number	:	815-758-8671
Fax Number	:	815-758-5610

Authorized Official
Title or Position	:	CHAIRMAN, BOARD OF DIRECTORS
Name	:	ROGER L HAAB
Credential	:	M.D.
Telephone Number	:	815-758-8671

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	04/30/2013

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Practice Location Address:

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1023018322 — ASRA F KHAN MD
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Practice Fax:

1497739569 — BRYAN M KRUSKOL DO
Practice Location Address:

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1508836586 — DR. CAROL A GILMORE MD
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1053371849 — CARRIE L KOPALA PA-C
Practice Location Address:

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Directions to “DEKALB CLINIC CHARTERED ” Practice Location

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