MEDICARE: PORTENO MEDICAL SERVICES, S.C.

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	36-083647	IL

General Provider Information

NPI Number	:	1982945838
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PORTENO MEDICAL SERVICES, S.C.

Provider Business Mailing Address
First Line	:	6142 S PULASKI RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60629-4628
Country	:	US
Telephone Number	:	773-767-4359
Fax Number	:	847-562-0202

Provider Business Practice Location Address
First Line	:	6142 S PULASKI RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60629-4628
Country	:	US
Telephone Number	:	773-767-4359
Fax Number	:	847-562-0202

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GREGORY ROSENSTEIN
Credential	:	M.D.
Telephone Number	:	773-580-5093

Provider Enumeration Date	:	03/01/2013
Last Update Date	:	03/01/2013

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