MEDICARE: PHYLLIS LEE PETERSON PT CHT

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	2590	TN
2	2251H1200X	Hand Physical Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0202418	OTHER	TN	BCBS OF TN

General Provider Information

NPI Number	:	1629157508
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHYLLIS LEE PETERSON PT CHT

Provider Business Mailing Address
First Line	:	790 REMINGTON BLVD
Second Line	:
City	:	BOLINGBROOK
State	:	IL
Zip	:	60440-4909
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3112 N OCOEE ST
Second Line	:
City	:	CLEVELAND
State	:	TN
Zip	:	37312
Country	:	US
Telephone Number	:	423-559-1537
Fax Number	:

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

Provider Enumeration Date	:	11/03/2006
Last Update Date	:	09/14/2015

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