MEDICARE: MR. GEOFFREY S DAVIS ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	96000466	IL

General Provider Information

NPI Number	:	1013088145
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GEOFFREY S DAVIS ATC

Provider Business Mailing Address
First Line	:	940 N HUMPHREY AVE
Second Line	:
City	:	OAK PARK
State	:	IL
Zip	:	60302-1418
Country	:	US
Telephone Number	:	708-763-0299
Fax Number	:

Provider Business Practice Location Address
First Line	:	9000 W COLLEGE PKWY
Second Line	:
City	:	PALOS HILLS
State	:	IL
Zip	:	60465-1444
Country	:	US
Telephone Number	:	708-974-5287
Fax Number	:	708-974-5420

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/12/2006
Last Update Date	:	07/08/2007

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