MEDICARE: LEONARD R JUBERT

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	213E00000X	Podiatrist	016004432	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	60001709	OTHER	IL	BLUE CROSS ID NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1760414460
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEONARD R JUBERT

Provider Business Mailing Address
First Line	:	8054 S WESTERN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60620-5936
Country	:	US
Telephone Number	:	773-776-9400
Fax Number	:	773-776-9644

Provider Business Practice Location Address
First Line	:	8054 S WESTERN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60620-5936
Country	:	US
Telephone Number	:	773-776-9400
Fax Number	:	773-776-9644

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

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	04/22/2008

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