MEDICARE: SAMUEL WARREN KOELLING 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	05013785A	IN

General Provider Information

NPI Number	:	1780294579
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL WARREN KOELLING DPT

Provider Business Mailing Address
First Line	:	2122 YORK RD STE 300
Second Line	:
City	:	OAK BROOK
State	:	IL
Zip	:	60523-1925
Country	:	US
Telephone Number	:	803-812-3656
Fax Number	:

Provider Business Practice Location Address
First Line	:	2902 W 86TH ST STE 60
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46268-4188
Country	:	US
Telephone Number	:	317-396-0870
Fax Number	:

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

Provider Enumeration Date	:	08/06/2020
Last Update Date	:	03/05/2026

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