=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235883208
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRICK DOVICHI PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2022
-----------------------------------------------------
Last Update Date | 02/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4021 W BELMONT AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60641-4771
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-328-5500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1801 W ERIE ST APT 1
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60622-5520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-933-7707
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 160004210
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------