MEDICARE: ATHLETIC AND THERAPEUTIC INSTITUTE OF NAPERVILLE, LLC

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	04732021	OTHER	IL	BLUE CROSS BLUE SHIELD
2	611827600	OTHER	IL	DEPARTMENT OF LABOR PROVIDER NUMBER
3	7400622	OTHER	IL	AETNA

General Provider Information

NPI Number	:	1457462053
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ATHLETIC AND THERAPEUTIC INSTITUTE OF NAPERVILLE, LLC

Provider Business Mailing Address
First Line	:	4947 PAYSPHERE CIR
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60674-0049
Country	:	US
Telephone Number	:	630-296-2223
Fax Number	:

Provider Business Practice Location Address
First Line	:	4511 STATE ROUTE 71
Second Line	:
City	:	OSWEGO
State	:	IL
Zip	:	60543-7416
Country	:	US
Telephone Number	:	630-554-7815
Fax Number	:	630-554-4849

Authorized Official
Title or Position	:	CHIEF COMPLIANCE OFFICER
Name	:	LYNN MCGIVERN
Credential	:
Telephone Number	:	630-296-2222

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	04/07/2011

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