MEDICARE: DENNIS W PROHASKA D. O.

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	363A00000X	Physician Assistant	1610-023	WI
2	363A00000X	Physician Assistant	085-002276	IL
3	207P00000X	Emergency Medicine Physician	085-002276	IL
4	2085R0202X	Diagnostic Radiology Physician	02004880B	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1689651010
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENNIS W PROHASKA D. O.

Provider Business Mailing Address
First Line	:	1516 S WABASH AVE
Second Line	:	APT 1104
City	:	CHICAGO
State	:	IL
Zip	:	60605-2903
Country	:	US
Telephone Number	:	414-870-5178
Fax Number	:

Provider Business Practice Location Address
First Line	:	1516 S WABASH AVE
Second Line	:	APT 1104
City	:	CHICAGO
State	:	IL
Zip	:	60605-2903
Country	:	US
Telephone Number	:	414-870-5178
Fax Number	:

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

Provider Enumeration Date	:	12/28/2005
Last Update Date	:	07/15/2016

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