MEDICARE: DR. PETER W. BROIDO 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	208600000X	Surgery Physician	036042407	IL

General Provider Information

NPI Number	:	1740446277
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PETER W. BROIDO M.D.

Provider Business Mailing Address
First Line	:	333 N. CANAL STREET
Second Line	:	UNIT 3504
City	:	CHICAGO
State	:	IL
Zip	:	60606-1543
Country	:	US
Telephone Number	:	312-575-8512
Fax Number	:	312-575-8513

Provider Business Practice Location Address
First Line	:	333 N. CANAL STREET
Second Line	:	UNIT 3504
City	:	CHICAGO
State	:	IL
Zip	:	60606-1543
Country	:	US
Telephone Number	:	312-575-8512
Fax Number	:	312-575-8513

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

Provider Enumeration Date	:	08/04/2008
Last Update Date	:	08/04/2008

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