=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417432253
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INDEPTH PHYSICAL THERAPY, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2018
-----------------------------------------------------
Last Update Date | 02/08/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2549 N RACINE AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60614-2131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 331-230-8796
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2549 N RACINE AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60614-2131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 331-230-8796
-----------------------------------------------------
Fax | 773-797-9404
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST, OWNER
-----------------------------------------------------
Name | STEPHANIE KORSO
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 331-230-8796
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------