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NPI Code Detail

MEDICARE: CAROLYN SEHLBREDE BANNER RD, LDN

MEDICARE: CAROLYN SEHLBREDE BANNER RD, LDN
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
1133V00000XRegistered DietitianIL

General Provider Information

NPI Number : 1619065216
Entity Type Code : Individual
Provider Name (Legal Business Name) : CAROLYN SEHLBREDE BANNER RD, LDN
Provider Business Mailing Address
First Line : 5110 S HYDE PARK BLVD
Second Line : APT 3A
City : CHICAGO
State : IL
Zip : 60615-4272
Country : US
Telephone Number : 773-702-4548
Fax Number : 773-702-3565
Provider Business Practice Location Address
First Line : 1531 E HYDE PARK BLVD
Second Line : UNIVERSITY OF CHICAGO HOSPITALS LAKE PARK DIALYSIS UNIT
City : CHICAGO
State : IL
Zip : 60615-3039
Country : US
Telephone Number : 773-702-4548
Fax Number : 773-702-3565
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/10/2006
Last Update Date : 07/08/2007

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