MEDICARE: MR. ANDREY I PARVANOV P.T.

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	070-011637	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3049325227	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1740328921
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ANDREY I PARVANOV P.T.

Provider Business Mailing Address
First Line	:	47 SYLVAN CT
Second Line	:
City	:	ELK GROVE VILLAGE
State	:	IL
Zip	:	60007-3565
Country	:	US
Telephone Number	:	312-898-8085
Fax Number	:

Provider Business Practice Location Address
First Line	:	47 SYLVAN CT
Second Line	:
City	:	ELK GROVE VILLAGE
State	:	IL
Zip	:	60007
Country	:	US
Telephone Number	:	312-898-8085
Fax Number	:

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

Provider Enumeration Date	:	02/01/2007
Last Update Date	:	12/23/2018

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