Healthcare Provider Details

I. General information

NPI: 1700928462
Provider Name (Legal Business Name): MICHAEL WALKER MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 11/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3644 W 111TH STREET
CHICAGO IL
60655-2609
US

IV. Provider business mailing address

3644 W 111TH STREET
CHICAGO IL
60655-2609
US

V. Phone/Fax

Practice location:
  • Phone: 773-779-8480
  • Fax: 773-779-8404
Mailing address:
  • Phone: 773-779-8480
  • Fax: 773-779-8404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070012529
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: