Healthcare Provider Details

I. General information

NPI: 1134677784
Provider Name (Legal Business Name): MADELINE PELLIKAN MS, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2016
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 WAUKEGAN RD STE 200
MORTON GROVE IL
60053-2127
US

IV. Provider business mailing address

9000 WAUKEGAN RD STE 200
MORTON GROVE IL
60053-2127
US

V. Phone/Fax

Practice location:
  • Phone: 847-778-6632
  • Fax:
Mailing address:
  • Phone: 847-778-6632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096005417
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT. 005003
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: