MEDICARE: DR. LOLITA CRISOSTOMO 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	2084P0800X	Psychiatry Physician		IL

General Provider Information

NPI Number	:	1871648360
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LOLITA CRISOSTOMO M.D.

Provider Business Mailing Address
First Line	:	4200 N OAK PARK AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-1417
Country	:	US
Telephone Number	:	773-794-4000
Fax Number	:	773-794-4046

Provider Business Practice Location Address
First Line	:	4200 N OAK PARK AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-1417
Country	:	US
Telephone Number	:	773-794-4000
Fax Number	:	773-794-4046

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

Provider Enumeration Date	:	01/24/2007
Last Update Date	:	07/08/2007

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