Healthcare Provider Details

I. General information

NPI: 1699688036
Provider Name (Legal Business Name): SEVERIANO FERNANDEZ PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E RANDOLPH ST STE 5100
CHICAGO IL
60601-6528
US

IV. Provider business mailing address

3614 W GEORGE ST APT 2F
CHICAGO IL
60618-7882
US

V. Phone/Fax

Practice location:
  • Phone: 630-474-2759
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160.010110
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: