MEDICARE: MADHUR DASS APRN

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	363LF0000X	Family Nurse Practitioner	209.026403	IL

General Provider Information

NPI Number	:	1487356333
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADHUR DASS APRN

Provider Business Mailing Address
First Line	:	1122 WILLOW RD
Second Line	:
City	:	NORTHBROOK
State	:	IL
Zip	:	60062-6824
Country	:	US
Telephone Number	:	847-714-1220
Fax Number	:	847-714-1235

Provider Business Practice Location Address
First Line	:	1122 WILLOW RD
Second Line	:
City	:	NORTHBROOK
State	:	IL
Zip	:	60062-6824
Country	:	US
Telephone Number	:	847-714-1220
Fax Number	:	847-714-1235

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

Provider Enumeration Date	:	03/21/2023
Last Update Date	:	05/11/2023

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