MEDICARE: ANDREW WILLSON

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	096.003776	IL

General Provider Information

NPI Number	:	1932517919
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANDREW WILLSON

Provider Business Mailing Address
First Line	:	915 W CARMEN AVE
Second Line	:	APT 506
City	:	CHICAGO
State	:	IL
Zip	:	60640-3261
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	915 W CARMEN AVE
Second Line	:	APT 506
City	:	CHICAGO
State	:	IL
Zip	:	60640-3261
Country	:	US
Telephone Number	:	269-598-1758
Fax Number	:

Authorized Official
Title or Position	:	ATHLETIC TRAINER
Name	:	ANDREW WILLSON
Credential	:	ATC
Telephone Number	:	269-598-1758

Provider Enumeration Date	:	07/23/2014
Last Update Date	:	07/23/2014

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