MEDICARE: DR. JERRY RENATO COLTRO 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	207R00000X	Internal Medicine Physician	036070297	IL
2	207RR0500X	Rheumatology Physician	036070297	IL

General Provider Information

NPI Number	:	1962456442
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JERRY RENATO COLTRO M.D.

Provider Business Mailing Address
First Line	:	9830 RIDGELAND AVE
Second Line	:	SUITE 7
City	:	CHICAGO RIDGE
State	:	IL
Zip	:	60415-2668
Country	:	US
Telephone Number	:	708-422-6800
Fax Number	:	708-422-6888

Provider Business Practice Location Address
First Line	:	9830 RIDGELAND AVE
Second Line	:	SUITE 7
City	:	CHICAGO RIDGE
State	:	IL
Zip	:	60415-2667
Country	:	US
Telephone Number	:	708-422-6800
Fax Number	:	708-422-6888

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

Provider Enumeration Date	:	05/20/2006
Last Update Date	:	01/11/2012

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