MEDICARE: CORI MACK P.T

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	070012671	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00082059	OTHER	IL	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1578610259
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CORI MACK P.T

Provider Business Mailing Address
First Line	:	1946 W NEWPORT AVE APT 3E
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-1124
Country	:	US
Telephone Number	:	773-750-4560
Fax Number	:	312-527-9202

Provider Business Practice Location Address
First Line	:	227 E ONTARIO ST
Second Line	:	SUITE 201
City	:	CHICAGO
State	:	IL
Zip	:	60611-3385
Country	:	US
Telephone Number	:	773-417-6689
Fax Number	:	312-527-9202

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

Provider Enumeration Date	:	01/04/2007
Last Update Date	:	02/25/2015

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