MEDICARE: KEVIN MICHAEL PILLIFANT ATC

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	0497	AZ

General Provider Information

NPI Number	:	1750362596
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN MICHAEL PILLIFANT ATC

Provider Business Mailing Address
First Line	:	PO BOX 5165
Second Line	:
City	:	FRISCO
State	:	CO
Zip	:	80443-5165
Country	:	US
Telephone Number	:	520-429-7627
Fax Number	:

Provider Business Practice Location Address
First Line	:	CHICAGO WHITE SOX
Second Line	:	2500 EAST AJO WAY
City	:	TUCSON
State	:	AZ
Zip	:	85713
Country	:	US
Telephone Number	:	520-434-1263
Fax Number	:

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

Provider Enumeration Date	:	11/09/2005
Last Update Date	:	07/08/2007

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