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General NPI Number Information
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NPI Number | 1275598161
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Entity Type | Individual
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Provider Name | MICHAEL PATRICK PENDERGAST SR. ATC
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Gender | Male
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Dates
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Enumeration Date | 04/20/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | WESTERN ILLINOS UNIVERSITY ATHLETIC DEPT. ONE UNIV. CIRCLE
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City | MACOMB
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State | IL
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Zip | 61455
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Country | US
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Telephone | 309-208-1253
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Fax |
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Provider Business Mailing Address
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Address Line | 340 W PIERCE ST
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City | MACOMB
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State | IL
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Zip | 61455-1443
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Country | US
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Telephone | 309-833-5316
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number |
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License Number State | IL
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