=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912141847
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAMMARA ELISE ROBERSON-GREEN PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2009
-----------------------------------------------------
Last Update Date | 04/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1370 RING RD
-----------------------------------------------------
City | CALUMET CITY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60409-5428
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-217-2667
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17840 CEDAR AVE
-----------------------------------------------------
City | COUNTRY CLUB HILLS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60478-4733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-217-2667
-----------------------------------------------------
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 | 070.005013
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------