MEDICARE: ANDREA IRENE RUTHERFORD PA

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	96001592	IL
2	363AM0700X	Medical Physician Assistant	085003364	IL

General Provider Information

NPI Number	:	1720056229
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA IRENE RUTHERFORD PA

Provider Business Mailing Address
First Line	:	1860 PAYSPHERE CIR
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60674-0018
Country	:	US
Telephone Number	:	630-469-9200
Fax Number	:

Provider Business Practice Location Address
First Line	:	40 S CLAY ST
Second Line	:
City	:	HINSDALE
State	:	IL
Zip	:	60521-3257
Country	:	US
Telephone Number	:	630-286-5050
Fax Number	:	630-286-5052

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

Provider Enumeration Date	:	03/09/2006
Last Update Date	:	06/17/2022

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Directions to “ ANDREA IRENE RUTHERFORD PA” Practice Location

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