MEDICARE: VIRU SC

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	036-115930	IL

General Provider Information

NPI Number	:	1922294503
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VIRU SC

Provider Business Mailing Address
First Line	:	2412 W FULLERTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-3155
Country	:	US
Telephone Number	:	773-423-6178
Fax Number	:	773-451-8285

Provider Business Practice Location Address
First Line	:	2412 W FULLERTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-3155
Country	:	US
Telephone Number	:	773-423-6178
Fax Number	:	773-451-8285

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JACQUELINE OLIVO
Credential	:	M.D.
Telephone Number	:	773-716-7281

Provider Enumeration Date	:	09/18/2007
Last Update Date	:	07/13/2021

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Directions to “VIRU SC ” Practice Location

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