=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841934916
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES CLARK COSTEN PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2022
-----------------------------------------------------
Last Update Date | 04/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 N WABASH AVE STE 2109
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60602-2935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-368-4344
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 N WABASH AVE STE 2109
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60602-2935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-368-4344
-----------------------------------------------------
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 | 070011386
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------