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NPI Code Detail

MEDICARE: ANDREW SHADEL ATC

MEDICARE: ANDREW SHADEL 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
12255A2300XAthletic Trainer

General Provider Information

NPI Number : 1023424595
Entity Type Code : Individual
Provider Name (Legal Business Name) : ANDREW SHADEL ATC
Provider Business Mailing Address
First Line : 3313 SHADOWOOD DR
Second Line :
City : CRYSTAL LAKE
State : IL
Zip : 60012-1337
Country : US
Telephone Number : 815-353-7736
Fax Number :
Provider Business Practice Location Address
First Line : 100 197TH PL
Second Line :
City : CHICAGO HEIGHTS
State : IL
Zip : 60411-7539
Country : US
Telephone Number : 708-755-3020
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/06/2014
Last Update Date : 01/13/2015

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