MEDICARE: MICHAEL WALLER

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	225500000X	Respiratory/Developmental/Rehabilitative Specialist/Technologist	954494	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7454077	OTHER	IL	AETNA
2	01622333	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1558542241
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL WALLER

Provider Business Mailing Address
First Line	:	12400 S HARLEM AVE
Second Line	:
City	:	PALOS HEIGHTS
State	:	IL
Zip	:	60463-1440
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 HART RD
Second Line	:	SUITE 115
City	:	BARRINGTON
State	:	IL
Zip	:	60010-2623
Country	:	US
Telephone Number	:	847-277-7444
Fax Number	:

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

Provider Enumeration Date	:	11/21/2007
Last Update Date	:	11/21/2007

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