=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821025289
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | G & T ORTHOPAEDICS AND SPORTS MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2006
-----------------------------------------------------
Last Update Date | 06/10/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 S YORK RD SUITE 4190
-----------------------------------------------------
City | ELMHURST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60126-5626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-782-1174
-----------------------------------------------------
Fax | 773-275-2443
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1200 S YORK RD SUITE 4190
-----------------------------------------------------
City | ELMHURST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60126-5626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-782-1174
-----------------------------------------------------
Fax | 773-275-2443
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | CHRISTOS GIANNOULIAS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 630-782-1174
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XX0005X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------