MEDICARE: KEHINDE A. HATTISBURG

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	235Z00000X	Speech-Language Pathologist	146.010211	IL

General Provider Information

NPI Number	:	1740502475
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEHINDE A. HATTISBURG

Provider Business Mailing Address
First Line	:	913 E 54TH ST
Second Line	:	#206
City	:	CHICAGO
State	:	IL
Zip	:	60615-5019
Country	:	US
Telephone Number	:	773-493-4000
Fax Number	:

Provider Business Practice Location Address
First Line	:	913 E 54TH ST
Second Line	:	#206
City	:	CHICAGO
State	:	IL
Zip	:	60615-5019
Country	:	US
Telephone Number	:	773-493-4000
Fax Number	:

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

Provider Enumeration Date	:	02/22/2010
Last Update Date	:	11/22/2010

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