MEDICARE: DR. JOSE L. MEDINA M.D.

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	174400000X	Specialist		IL

General Provider Information

NPI Number	:	1679673214
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOSE L. MEDINA M.D.

Provider Business Mailing Address
First Line	:	5015 N PAULINA ST
Second Line	:	SUITE 325
City	:	CHICAGO
State	:	IL
Zip	:	60640-2756
Country	:	US
Telephone Number	:	773-775-7540
Fax Number	:	773-763-9792

Provider Business Practice Location Address
First Line	:	5015 N PAULINA ST
Second Line	:	SUITE 325
City	:	CHICAGO
State	:	IL
Zip	:	60640-2756
Country	:	US
Telephone Number	:	773-775-7540
Fax Number	:	773-763-9792

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

Provider Enumeration Date	:	09/24/2006
Last Update Date	:	07/08/2007

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