MEDICARE: MARIO C. ROSAS 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	207Q00000X	Family Medicine Physician	036074065	IL

General Provider Information

NPI Number	:	1841369881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIO C. ROSAS M.D.

Provider Business Mailing Address
First Line	:	2619 S LAWNDALE AVE
Second Line	:	FRONT
City	:	CHICAGO
State	:	IL
Zip	:	60623-4520
Country	:	US
Telephone Number	:	773-522-2620
Fax Number	:	773-522-2641

Provider Business Practice Location Address
First Line	:	2619 S LAWNDALE AVE
Second Line	:	FRONT
City	:	CHICAGO
State	:	IL
Zip	:	60623-4520
Country	:	US
Telephone Number	:	773-522-2620
Fax Number	:	773-522-2641

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

Provider Enumeration Date	:	11/06/2006
Last Update Date	:	09/28/2018

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