MEDICARE: RENEE LEIGH PEDERSEN PT, 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
1	225100000X	Physical Therapist	10064	SC
2	225100000X	Physical Therapist	PT38966	FL
3	225100000X	Physical Therapist	070.018745	IL
4	225100000X	Physical Therapist	297988	CA

General Provider Information

NPI Number	:	1689924680
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RENEE LEIGH PEDERSEN PT, DPT

Provider Business Mailing Address
First Line	:	1401 S CALIFORNIA AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-1858
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1401 S. CALIFORNIA BLVD.
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608
Country	:	US
Telephone Number	:	773-522-2010
Fax Number	:

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

Provider Enumeration Date	:	09/17/2012
Last Update Date	:	05/04/2026

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