MEDICARE: NICOLE C PHILLIPS PT

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	07-0017097	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00790089	OTHER	IL	MEDICARE RR

General Provider Information

NPI Number	:	1730314964
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE C PHILLIPS PT

Provider Business Mailing Address
First Line	:	790 REMINGTON BLVD
Second Line	:
City	:	BOLINGBROOK
State	:	IL
Zip	:	60440-4909
Country	:	US
Telephone Number	:	630-296-2223
Fax Number	:

Provider Business Practice Location Address
First Line	:	7511 LEMONT RD
Second Line	:	SUITE 204
City	:	DARIEN
State	:	IL
Zip	:	60561-4394
Country	:	US
Telephone Number	:	630-985-4010
Fax Number	:

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

Provider Enumeration Date	:	05/18/2009
Last Update Date	:	03/08/2010

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Directions to “ NICOLE C PHILLIPS PT” Practice Location

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