MEDICARE: MRS. EMILY JO WHITSON 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	:	1629046024
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. EMILY JO WHITSON ATC

Provider Business Mailing Address
First Line	:	1419 RIDGEPORT AVE
Second Line	:
City	:	BLOOMINGTON
State	:	IL
Zip	:	61704-2335
Country	:	US
Telephone Number	:	309-661-8671
Fax Number	:

Provider Business Practice Location Address
First Line	:	222 NW GROVE STREET
Second Line	:	HOPEDALE MEDICAL COMPLEX
City	:	HOPEDALE
State	:	IL
Zip	:	61747
Country	:	US
Telephone Number	:	309-449-4501
Fax Number	:	309-449-4525

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

Provider Enumeration Date	:	03/10/2006
Last Update Date	:	07/08/2007

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