=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720499056
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MELINDA BALDWIN LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2014
-----------------------------------------------------
Last Update Date | 05/08/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 193 NORTHFIELD RD
-----------------------------------------------------
City | NORTHFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60093-3309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-828-4376
-----------------------------------------------------
Fax | 847-441-8999
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 835 ASH ST
-----------------------------------------------------
City | WINNETKA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60093-2401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-828-4376
-----------------------------------------------------
Fax | 847-441-8999
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST/OWNER
-----------------------------------------------------
Name | MELINDA BALDWIN
-----------------------------------------------------
Credential | MS, PT
-----------------------------------------------------
Telephone | 847-828-4376
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 070007921
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------