=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003209743
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KASEY ALAN THRUSH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2015
-----------------------------------------------------
Last Update Date | 03/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 507 E IRVING ST
-----------------------------------------------------
City | MILFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60953-1141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-592-4936
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 507 E IRVING STREET
-----------------------------------------------------
City | MILFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60953
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-592-4936
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | T62050193310
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------