MEDICARE: MARY ELLEN GREEN PT

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	225100000X	Physical Therapist	070.005875	IL

General Provider Information

NPI Number	:	1043769276
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY ELLEN GREEN PT

Provider Business Mailing Address
First Line	:	646 RIFORD RD
Second Line	:
City	:	GLEN ELLYN
State	:	IL
Zip	:	60137-3973
Country	:	US
Telephone Number	:	630-942-1068
Fax Number	:

Provider Business Practice Location Address
First Line	:	10255 SOUTHWEST HWY
Second Line	:
City	:	CHICAGO RIDGE
State	:	IL
Zip	:	60415-1350
Country	:	US
Telephone Number	:	708-778-0115
Fax Number	:

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

Provider Enumeration Date	:	09/29/2016
Last Update Date	:	09/29/2016

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