MEDICARE: MR. WENDELL WALTER JOHNSON

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

General Provider Information

NPI Number	:	1558449876
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WENDELL WALTER JOHNSON

Provider Business Mailing Address
First Line	:	12626 S ELIZABETH ST
Second Line	:
City	:	CALUMET PARK
State	:	IL
Zip	:	60827-6111
Country	:	US
Telephone Number	:	708-396-8923
Fax Number	:

Provider Business Practice Location Address
First Line	:	4735 N BEACON
Second Line	:	#109
City	:	CHICAGO
State	:	IL
Zip	:	60640
Country	:	US
Telephone Number	:	773-293-4575
Fax Number	:

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

Provider Enumeration Date	:	11/02/2006
Last Update Date	:	07/08/2007

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