MEDICARE: KRIS ALAN SCHWIDERSKI A.T.,C.

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		IL

General Provider Information

NPI Number	:	1902874092
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRIS ALAN SCHWIDERSKI A.T.,C.

Provider Business Mailing Address
First Line	:	1600 W WALNUT ST
Second Line	:
City	:	JACKSONVILLE
State	:	IL
Zip	:	62650-1136
Country	:	US
Telephone Number	:	217-245-9541
Fax Number	:	217-479-5675

Provider Business Practice Location Address
First Line	:	1600 W WALNUT ST
Second Line	:
City	:	JACKSONVILLE
State	:	IL
Zip	:	62650-1136
Country	:	US
Telephone Number	:	217-245-9541
Fax Number	:	217-479-5675

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

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	07/08/2007

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