MEDICARE: ADVANTAGE PHYSICAL THERAPY ASSOCIATES, SC

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	070-002882	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1164680492	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1164680492
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANTAGE PHYSICAL THERAPY ASSOCIATES, SC

Provider Business Mailing Address
First Line	:	PO BOX 72180
Second Line	:
City	:	ROSELLE
State	:	IL
Zip	:	60172-0180
Country	:	US
Telephone Number	:	630-792-9790
Fax Number	:	630-792-9794

Provider Business Practice Location Address
First Line	:	6234 MAIN ST
Second Line	:
City	:	DOWNERS GROVE
State	:	IL
Zip	:	60516-1908
Country	:	US
Telephone Number	:	630-960-9914
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JAMES A DALLAS
Credential	:	LPT
Telephone Number	:	630-792-9790

Provider Enumeration Date	:	05/22/2008
Last Update Date	:	03/04/2009

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