MEDICARE: MJ MEDICAL GROUP SC

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		IL

General Provider Information

NPI Number	:	1649224148
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MJ MEDICAL GROUP SC

Provider Business Mailing Address
First Line	:	6326 N LINCOLN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-1204
Country	:	US
Telephone Number	:	773-463-4100
Fax Number	:	773-463-4102

Provider Business Practice Location Address
First Line	:	6326 N LINCOLN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-1204
Country	:	US
Telephone Number	:	773-463-4100
Fax Number	:	773-463-4102

Authorized Official
Title or Position	:	CEO
Name	:	MICHAEL H JUTOVSKY
Credential	:	MD
Telephone Number	:	773-463-4100

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	08/23/2011

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