MEDICARE: UNIVERSITY OF ILLINOIS AT CHICAGO

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	282N00000X	General Acute Care Hospital	070.010259	IL

General Provider Information

NPI Number	:	1649522095
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNIVERSITY OF ILLINOIS AT CHICAGO

Provider Business Mailing Address
First Line	:	34 MARENGO AVE UNIT A
Second Line	:
City	:	FOREST PARK
State	:	IL
Zip	:	60130-1107
Country	:	US
Telephone Number	:	708-488-9045
Fax Number	:

Provider Business Practice Location Address
First Line	:	1919 WEST TAYLOR - 650 AHSB
Second Line	:	DEPARTMENT OF KINESIOLOGY AN
City	:	CHICAGO
State	:	IL
Zip	:	60612
Country	:	US
Telephone Number	:	708-507-0154
Fax Number	:

Authorized Official
Title or Position	:	SPECIAIST IN PT
Name	:	MS. JULIE ANN ROBICHAUD
Credential	:	PT, PHD
Telephone Number	:	312-355-9600

Provider Enumeration Date	:	10/10/2012
Last Update Date	:	10/10/2012

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