=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134193691
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RENEE L POLUBINSKY ATC, CSCS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 UNIVERSITY CIR
-----------------------------------------------------
City | MACOMB
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61455-1367
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-298-2050
-----------------------------------------------------
Fax | 309-298-2981
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30 SHOREWOOD DR
-----------------------------------------------------
City | MACOMB
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61455-9746
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-298-2050
-----------------------------------------------------
Fax | 309-298-2981
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------