=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982953881
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH GEZAW PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2012
-----------------------------------------------------
Last Update Date | 09/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6701 159TH ST
-----------------------------------------------------
City | TINLEY PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60477-1758
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-915-7460
-----------------------------------------------------
Fax | 708-915-7379
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6825 CHELSEA RD
-----------------------------------------------------
City | TINLEY PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60477-1734
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-717-5060
-----------------------------------------------------
Fax | 708-915-7379
-----------------------------------------------------
=====================================================
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 | 070.005956
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------