MEDICARE: DR. BROJENDRA AGARWALA M.D.

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	2080P0202X	Pediatric Cardiology Physician	036046668	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01621679	OTHER	IL	BCBS OF IL
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780668285
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BROJENDRA AGARWALA M.D.

Provider Business Mailing Address
First Line	:	5841 S MARYLAND AVE
Second Line	:	MC 4051
City	:	CHICAGO
State	:	IL
Zip	:	60637-1447
Country	:	US
Telephone Number	:	773-795-4475
Fax Number	:	773-702-2319

Provider Business Practice Location Address
First Line	:	5841 S MARYLAND AVE
Second Line	:	MC 4051
City	:	CHICAGO
State	:	IL
Zip	:	60637-1447
Country	:	US
Telephone Number	:	773-795-4475
Fax Number	:	773-702-2319

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

Provider Enumeration Date	:	11/30/2005
Last Update Date	:	03/14/2013

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