MEDICARE: MICHAEL DEAN DRALLE ATC

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	2255A2300X	Athletic Trainer		IL

General Provider Information

NPI Number	:	1568431377
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL DEAN DRALLE ATC

Provider Business Mailing Address
First Line	:	522 WENNES CT
Second Line	:
City	:	OAK BROOK
State	:	IL
Zip	:	60523-2727
Country	:	US
Telephone Number	:	630-654-3485
Fax Number	:

Provider Business Practice Location Address
First Line	:	8937 GRAND AVE
Second Line	:	ATHLETICO SPORTS MEDICINE AND PT CENTERS
City	:	RIVER GROVE
State	:	IL
Zip	:	60171
Country	:	US
Telephone Number	:	708-453-1354
Fax Number	:	708-453-2679

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

Provider Enumeration Date	:	03/15/2006
Last Update Date	:	07/08/2007

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