MEDICARE: ANNIE LAURIE WIDLICKA MS, 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
1	133V00000X	Registered Dietitian		IL

General Provider Information

NPI Number	:	1629098231
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANNIE LAURIE WIDLICKA MS, RD, LDN

Provider Business Mailing Address
First Line	:	541 W OAKDALE AVE APT 509
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657
Country	:	US
Telephone Number	:	773-857-3578
Fax Number	:

Provider Business Practice Location Address
First Line	:	5841 S MARYLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60637-1470
Country	:	US
Telephone Number	:	773-702-1000
Fax Number	:

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

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	07/08/2007

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