MEDICARE: JERRY PORZEMSKY, PH.D. P.C.

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	103TC0700X	Clinical Psychologist	071001197	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01672054	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1598084154
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JERRY PORZEMSKY, PH.D. P.C.

Provider Business Mailing Address
First Line	:	2909 W FARGO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60645-1222
Country	:	US
Telephone Number	:	773-262-5757
Fax Number	:	773-262-4018

Provider Business Practice Location Address
First Line	:	2909 W FARGO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60645-1222
Country	:	US
Telephone Number	:	773-262-5757
Fax Number	:	773-262-4018

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JERRY MARVIN PORZEMSKY
Credential	:	PH.D.
Telephone Number	:	773-262-5757

Provider Enumeration Date	:	05/21/2010
Last Update Date	:	06/24/2010

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