Healthcare Provider Details

I. General information

NPI: 1952510364
Provider Name (Legal Business Name): BRUCE FUGGITI PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 10/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8337 W LAWRENCE AVE
NORRIDGE IL
60706-3129
US

IV. Provider business mailing address

6450 W BERTEAU AVE APT 306
CHICAGO IL
60634-6243
US

V. Phone/Fax

Practice location:
  • Phone: 708-583-9500
  • Fax: 708-583-9501
Mailing address:
  • Phone: 773-282-5485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License Number070.04098
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number07000498
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: