Healthcare Provider Details

I. General information

NPI: 1639589658
Provider Name (Legal Business Name): GREGORY RAKERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2014
Last Update Date: 04/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8658 S COTTAGE GROVE UNIT 400
CHICAGO IL
60619-6192
US

IV. Provider business mailing address

205 W WACKER DR SUITE 120
CHICAGO IL
60606-1216
US

V. Phone/Fax

Practice location:
  • Phone: 773-723-1270
  • Fax: 773-723-1280
Mailing address:
  • Phone: 312-640-0329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070019577
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: