MEDICARE: MRS. MATT WINDHAM JR.

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	171W00000X	Contractor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	V797P-4898A	OTHER	IL	NATIONAL ACQUISTION VA

General Provider Information

NPI Number	:	1790886398
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MATT WINDHAM JR.

Provider Business Mailing Address
First Line	:	2056 E 71ST ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60649-2117
Country	:	US
Telephone Number	:	773-288-2844
Fax Number	:	773-288-2848

Provider Business Practice Location Address
First Line	:	2056 E 71ST ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60649-2117
Country	:	US
Telephone Number	:	773-288-2844
Fax Number	:	773-288-2848

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

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	07/08/2007

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