=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164731725
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY E MOSKAL BUCKLEY DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2010
-----------------------------------------------------
Last Update Date | 05/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12360 PRINCETON DR
-----------------------------------------------------
City | HUNTLEY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60142-7655
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-961-5500
-----------------------------------------------------
Fax | 847-961-5588
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2122 YORK RD STE 300
-----------------------------------------------------
City | OAK BROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60523-1925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-575-1980
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number | 070.017866
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------