=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467888974
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD SEVERIN PT, DPT, PHD, CCS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2013
-----------------------------------------------------
Last Update Date | 02/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1640 W ROOSEVELT RD
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60608-1316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-413-8043
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1919 W TAYLOR ST # MC898
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60612-7246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-413-5228
-----------------------------------------------------
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 | 070021127
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2251C2600X
-----------------------------------------------------
Taxonomy Name | Cardiopulmonary Physical Therapist
-----------------------------------------------------
License Number | 070021127
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------