MEDICARE: INDEPENDENCE PHYSICAL THERAPY, PC

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

General Provider Information

NPI Number	:	1134456007
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDEPENDENCE PHYSICAL THERAPY, PC

Provider Business Mailing Address
First Line	:	1397 MAIN ST
Second Line	:
City	:	CRETE
State	:	IL
Zip	:	60417-2951
Country	:	US
Telephone Number	:	708-367-8050
Fax Number	:	708-367-8051

Provider Business Practice Location Address
First Line	:	1397 MAIN ST
Second Line	:
City	:	CRETE
State	:	IL
Zip	:	60417-2951
Country	:	US
Telephone Number	:	708-367-8050
Fax Number	:	708-367-8051

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BARBARA J GERK
Credential	:
Telephone Number	:	708-638-8809

Provider Enumeration Date	:	11/12/2009
Last Update Date	:	09/29/2010

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