Healthcare Provider Details

I. General information

NPI: 1770703407
Provider Name (Legal Business Name): AMY L PANOKA PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY L RUDNICK PT

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 12/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 E HURON ST SUITE 901
CHICAGO IL
60611-2999
US

IV. Provider business mailing address

205 W WACKER DR SUITE 1020
CHICAGO IL
60606-1216
US

V. Phone/Fax

Practice location:
  • Phone: 312-640-1112
  • Fax: 312-640-1011
Mailing address:
  • Phone: 312-640-0329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070013248
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: