MEDICARE: ADVANCED INTEGRATIVE MEDICAL LLC

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	363LF0000X	Family Nurse Practitioner	209012388	IL

General Provider Information

NPI Number	:	1811343072
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED INTEGRATIVE MEDICAL LLC

Provider Business Mailing Address
First Line	:	202 N SPRUCE DR
Second Line	:
City	:	MAHOMET
State	:	IL
Zip	:	61853-9277
Country	:	US
Telephone Number	:	317-518-8166
Fax Number	:

Provider Business Practice Location Address
First Line	:	2333 N HARLEM AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60707-2718
Country	:	US
Telephone Number	:	317-518-8166
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	WILLIAM BLANCHARD
Credential	:
Telephone Number	:	317-518-8166

Provider Enumeration Date	:	05/06/2016
Last Update Date	:	05/25/2016

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