MEDICARE: SANDRA VERA PAVIC DO

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		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0001622511	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1770528481
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA VERA PAVIC DO

Provider Business Mailing Address
First Line	:	6439 WEST 63RD STREET
Second Line	:	APT 1C
City	:	CHICAGO
State	:	IL
Zip	:	60638-4148
Country	:	US
Telephone Number	:	773-572-4083
Fax Number	:

Provider Business Practice Location Address
First Line	:	6439 WEST 63RD STREET
Second Line	:	APT 1C
City	:	CHICAGO
State	:	IL
Zip	:	60638-4148
Country	:	US
Telephone Number	:	773-572-4083
Fax Number	:

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

Provider Enumeration Date	:	06/17/2006
Last Update Date	:	07/08/2007

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