MEDICARE: DR. JOHNSON MAO M.D.

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	174400000X	Specialist	36050106	IL

General Provider Information

NPI Number	:	1538107321
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHNSON MAO M.D.

Provider Business Mailing Address
First Line	:	2600 S MICHIGAN AVE
Second Line	:	#403
City	:	CHICAGO
State	:	IL
Zip	:	60616-2857
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2506 N CLARK ST
Second Line	:	#282
City	:	CHICAGO
State	:	IL
Zip	:	60614-1848
Country	:	US
Telephone Number	:	312-842-8210
Fax Number	:	312-842-8281

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

Provider Enumeration Date	:	06/03/2006
Last Update Date	:	07/08/2007

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