MEDICARE: LISA BROOKE COHEN D.P.M.

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	213ES0103X	Foot & Ankle Surgery Podiatrist	016005305	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01600112	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1760644124
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA BROOKE COHEN D.P.M.

Provider Business Mailing Address
First Line	:	5012 W LAWRENCE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-3822
Country	:	US
Telephone Number	:	773-282-3377
Fax Number	:	773-205-4439

Provider Business Practice Location Address
First Line	:	5012 W LAWRENCE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-3822
Country	:	US
Telephone Number	:	773-282-3377
Fax Number	:	773-205-4439

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

Provider Enumeration Date	:	06/27/2008
Last Update Date	:	01/26/2011

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