MEDICARE: TAYLOR HISEK RD

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	133V00000X	Registered Dietitian	164.008141	IL

General Provider Information

NPI Number	:	1548906704
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAYLOR HISEK RD

Provider Business Mailing Address
First Line	:	1 E DELAWARE PL APT 16A
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-4974
Country	:	US
Telephone Number	:	440-251-6736
Fax Number	:

Provider Business Practice Location Address
First Line	:	250 E SUPERIOR ST STE 11-2134
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-2914
Country	:	US
Telephone Number	:	312-472-4933
Fax Number	:

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

Provider Enumeration Date	:	05/10/2022
Last Update Date	:	05/10/2022

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