MEDICARE: MS. VIVIAN PAN C.G.C.

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	170300000X	Genetic Counselor (M.S.)	74000062A	IN
2	170300000X	Genetic Counselor (M.S.)	247000040	IL

General Provider Information

NPI Number	:	1750721049
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. VIVIAN PAN C.G.C.

Provider Business Mailing Address
First Line	:	4525 N WESTERN AVE APT 4A
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-6933
Country	:	US
Telephone Number	:	312-952-2584
Fax Number	:	312-996-5760

Provider Business Practice Location Address
First Line	:	818 S WOLCOTT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-3702
Country	:	US
Telephone Number	:	312-413-4478
Fax Number	:	312-996-5760

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

Provider Enumeration Date	:	07/01/2013
Last Update Date	:	03/27/2024

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