=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407467376
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIMOTHY FERGUS PT, DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2020
-----------------------------------------------------
Last Update Date | 08/13/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1438 W CHESTNUT ST APT 3R
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60642-5329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-765-4375
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5800 LONETREE BLVD STE 101
-----------------------------------------------------
City | ROCKLIN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95765-3785
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------