MEDICARE: MONICA MEDRANO MD, MS

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	036.158389	IL
2	207Q00000X	Family Medicine Physician	01088219A	IN

General Provider Information

NPI Number	:	1821655663
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MONICA MEDRANO MD, MS

Provider Business Mailing Address
First Line	:	2508 N ASHLAND AVE # 2F
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-2004
Country	:	US
Telephone Number	:	773-807-1110
Fax Number	:

Provider Business Practice Location Address
First Line	:	3012 FRANKLIN ST
Second Line	:
City	:	MICHIGAN CITY
State	:	IN
Zip	:	46360-6144
Country	:	US
Telephone Number	:	219-877-3841
Fax Number	:

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

Provider Enumeration Date	:	05/28/2019
Last Update Date	:	08/16/2022

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