MEDICARE: RUSTUM HEALTH NETWORK

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	207Q00000X	Family Medicine Physician	036044669	IL
2	207R00000X	Internal Medicine Physician	036083101	IL

General Provider Information

NPI Number	:	1760821839
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RUSTUM HEALTH NETWORK

Provider Business Mailing Address
First Line	:	PO BOX 220278
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-0278
Country	:	US
Telephone Number	:	773-823-1802
Fax Number	:	773-823-1814

Provider Business Practice Location Address
First Line	:	2827 W CERMAK RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60623-3513
Country	:	US
Telephone Number	:	773-823-1802
Fax Number	:	773-823-1814

Authorized Official
Title or Position	:	OWNER
Name	:	AMER RUSTUM
Credential	:	MD
Telephone Number	:	773-283-1802

Provider Enumeration Date	:	06/21/2013
Last Update Date	:	06/21/2013

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