MEDICARE: MR. SERGEI SMUS LMT

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	225700000X	Massage Therapist		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01635656	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1487621751
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SERGEI SMUS LMT

Provider Business Mailing Address
First Line	:	1546 BARCLAY BLVD
Second Line	:
City	:	BUFFALO GROVE
State	:	IL
Zip	:	60089-4530
Country	:	US
Telephone Number	:	847-465-8415
Fax Number	:	847-465-8608

Provider Business Practice Location Address
First Line	:	1546 BARCLAY BLVD
Second Line	:
City	:	BUFFALO GROVE
State	:	IL
Zip	:	60089-4530
Country	:	US
Telephone Number	:	847-465-8415
Fax Number	:	847-465-8608

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

Provider Enumeration Date	:	03/03/2006
Last Update Date	:	07/08/2007

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Directions to “ MR. SERGEI SMUS LMT” Practice Location

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