MEDICARE: SIMEON A SEVANDAL JR. MD

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	207RG0300X	Geriatric Medicine (Internal Medicine) Physician	3654903	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528052735
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SIMEON A SEVANDAL JR. MD

Provider Business Mailing Address
First Line	:	3339 W 55TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60632
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3339 W 55TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60632
Country	:	US
Telephone Number	:	773-471-3600
Fax Number	:	773-471-3602

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

Provider Enumeration Date	:	09/01/2005
Last Update Date	:	09/30/2011

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