=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548572969
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST. MARY THERAPY SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2010
-----------------------------------------------------
Last Update Date | 05/30/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2455 W 79TH ST #101
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60652
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-737-8000
-----------------------------------------------------
Fax | 773-737-8001
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7903. W. 159TH ST #A
-----------------------------------------------------
City | TINLEY PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60477
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-444-3000
-----------------------------------------------------
Fax | 708-444-3003
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. ASHRAF N YOUSSIEF
-----------------------------------------------------
Credential | P.T
-----------------------------------------------------
Telephone | 708-945-8416
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 070-007546
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------