MEDICARE: MICHAEL RILEY JR. PT

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		IL

General Provider Information

NPI Number	:	1972727022
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL RILEY JR. PT

Provider Business Mailing Address
First Line	:	2071 GOOSE LAKE RD
Second Line	:
City	:	SAUGET
State	:	IL
Zip	:	62206-2822
Country	:	US
Telephone Number	:	618-337-9450
Fax Number	:	618-337-9482

Provider Business Practice Location Address
First Line	:	2071 GOOSE LAKE RD
Second Line	:
City	:	SAUGET
State	:	IL
Zip	:	62206-2822
Country	:	US
Telephone Number	:	618-337-9450
Fax Number	:	618-337-9482

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

Provider Enumeration Date	:	04/12/2007
Last Update Date	:	07/08/2007

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