Healthcare Provider Details

I. General information

NPI: 1417107194
Provider Name (Legal Business Name): PHILLIP M. SPARACINO PT,DPT,OCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2008
Last Update Date: 05/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13614 CICERO AVE
CRESTWOOD IL
60445-1937
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 708-389-3077
  • Fax: 708-389-3545
Mailing address:
  • Phone: 312-640-0329
  • Fax: 312-640-0407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.001685
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: