MEDICARE: MRS. SARA R NIEDERHOFFER PT

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	070012716	IL
2	225100000X	Physical Therapist	2016030535	MO

General Provider Information

NPI Number	:	1568708519
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SARA R NIEDERHOFFER PT

Provider Business Mailing Address
First Line	:	625 ENTERPRISE DR
Second Line	:
City	:	OAK BROOK
State	:	IL
Zip	:	60523-8813
Country	:	US
Telephone Number	:	630-575-6200
Fax Number	:

Provider Business Practice Location Address
First Line	:	5300 N ILLINOIS ST
Second Line	:
City	:	FAIRVIEW HTS
State	:	IL
Zip	:	62208-3500
Country	:	US
Telephone Number	:	618-624-9300
Fax Number	:	618-624-9330

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

Provider Enumeration Date	:	12/19/2012
Last Update Date	:	09/20/2016

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