=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518285048
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TERRY MICHAEL RAMOS ROSAL P.T.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2010
-----------------------------------------------------
Last Update Date | 07/31/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4621 WEDGEWOOD COURT
-----------------------------------------------------
City | LISLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-999-1040
-----------------------------------------------------
Fax | 630-925-7412
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 386 CLUBHOUSE ST
-----------------------------------------------------
City | BOLINGBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60490
-----------------------------------------------------
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 | 070022971
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 031134
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------