MEDICARE: DR. JEREMY BRIAN CAMPBELL PT, DPT, CSCS

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	070020840	IL

General Provider Information

NPI Number	:	1063812162
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEREMY BRIAN CAMPBELL PT, DPT, CSCS

Provider Business Mailing Address
First Line	:	227 E ONTARIO ST
Second Line	:	SUITE 201
City	:	CHICAGO
State	:	IL
Zip	:	60611-3385
Country	:	US
Telephone Number	:	312-527-9201
Fax Number	:	312-527-9201

Provider Business Practice Location Address
First Line	:	227 E ONTARIO ST
Second Line	:	SUITE 201
City	:	CHICAGO
State	:	IL
Zip	:	60611-3385
Country	:	US
Telephone Number	:	312-527-9201
Fax Number	:	312-527-9201

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

Provider Enumeration Date	:	08/26/2014
Last Update Date	:	07/30/2015

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