Healthcare Provider Details

I. General information

NPI: 1760759492
Provider Name (Legal Business Name): AMANDA M MYRON PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2011
Last Update Date: 09/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 E SUPERIOR ST
CHICAGO IL
60611-2654
US

IV. Provider business mailing address

345 E. SUPERIOR ST
CHICAGO IL
60611-2654
US

V. Phone/Fax

Practice location:
  • Phone: 312-238-1000
  • Fax:
Mailing address:
  • Phone: 312-238-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070018763
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: