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NPI Code Detail

MEDICARE: TIFFANY GREEN DPT

MEDICARE: TIFFANY GREEN 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
1225100000XPhysical Therapist070015306IL

General Provider Information

NPI Number : 1619012523
Entity Type Code : Individual
Provider Name (Legal Business Name) : TIFFANY GREEN DPT
Provider Business Mailing Address
First Line : 5764 S ARCHER AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60638-1643
Country : US
Telephone Number : 773-284-0888
Fax Number : 773-284-0880
Provider Business Practice Location Address
First Line : 5764 S ARCHER AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60638-1643
Country : US
Telephone Number : 773-284-0888
Fax Number : 773-284-0880
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/20/2007
Last Update Date : 05/11/2010

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