MEDICARE: ASB MEDICAL CLINIC, LTD

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	208D00000X	General Practice Physician	36087494	IL

General Provider Information

NPI Number	:	1518308600
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ASB MEDICAL CLINIC, LTD

Provider Business Mailing Address
First Line	:	6033 W IRVING PARK RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-2521
Country	:	US
Telephone Number	:	773-777-4767
Fax Number	:	773-777-0328

Provider Business Practice Location Address
First Line	:	6033 W IRVING PARK RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-2521
Country	:	US
Telephone Number	:	773-777-4767
Fax Number	:	773-777-0328

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. ANNA K BANAS
Credential	:	MD
Telephone Number	:	773-777-4767

Provider Enumeration Date	:	07/17/2013
Last Update Date	:	07/17/2013

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