MEDICARE: DR. IDRIS OMOSANYA PT, DPT

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	070019896	IL

General Provider Information

NPI Number	:	1528492360
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IDRIS OMOSANYA PT, DPT

Provider Business Mailing Address
First Line	:	1750 E 87TH ST STE 103
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60617-2706
Country	:	US
Telephone Number	:	800-618-6612
Fax Number	:	708-218-9112

Provider Business Practice Location Address
First Line	:	1750 E 87TH ST STE 103
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60617-2706
Country	:	US
Telephone Number	:	708-268-0862
Fax Number	:	708-218-9112

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

Provider Enumeration Date	:	08/28/2013
Last Update Date	:	02/26/2019

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