MEDICARE: JOSE R FERNANDEZ

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	036060326	IL

General Provider Information

NPI Number	:	1841559713
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSE R FERNANDEZ

Provider Business Mailing Address
First Line	:	5637 NORTH COURTLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60631-2907
Country	:	US
Telephone Number	:	847-292-1489
Fax Number	:	847-292-1489

Provider Business Practice Location Address
First Line	:	5637 NORTH COURTLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60631-2907
Country	:	US
Telephone Number	:	847-292-1489
Fax Number	:	847-292-1489

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

Provider Enumeration Date	:	05/11/2012
Last Update Date	:	05/11/2012

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Directions to “ JOSE R FERNANDEZ ” Practice Location

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