MEDICARE: OTERO MEDICAL CENTER, S.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	207Q00000X	Family Medicine Physician	036102552	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1588776884	OTHER	IL	NPI INDIVIDUAL NUMBER
2	01626950	OTHER	IL	BLUE CROSS BLUE SHIELD OF ILLINOIS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639306640
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OTERO MEDICAL CENTER, S.C.

Provider Business Mailing Address
First Line	:	4911 W FULLERTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639-2505
Country	:	US
Telephone Number	:	773-772-4900
Fax Number	:	773-772-0298

Provider Business Practice Location Address
First Line	:	4911 W FULLERTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639-2505
Country	:	US
Telephone Number	:	773-772-4900
Fax Number	:	773-772-0298

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. WILLIAM E OTERO
Credential	:	MD
Telephone Number	:	773-772-4900

Provider Enumeration Date	:	06/17/2009
Last Update Date	:	08/08/2013

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