Healthcare Provider Details

I. General information

NPI: 1457298366
Provider Name (Legal Business Name): MAGDALENE MYRDA DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 W HARRISON ST STE 107
CHICAGO IL
60612-4861
US

IV. Provider business mailing address

PO BOX 735263
CHICAGO IL
60673-5263
US

V. Phone/Fax

Practice location:
  • Phone: 877-632-6637
  • Fax: 708-409-5179
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number070040843
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: