MEDICARE: ANDREW CLEVENGER

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	225100000X	Physical Therapist	070.028039	IL

General Provider Information

NPI Number	:	1033971411
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREW CLEVENGER

Provider Business Mailing Address
First Line	:	2121 W ROSCOE ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-9244
Country	:	US
Telephone Number	:	312-586-1185
Fax Number	:	312-586-1083

Provider Business Practice Location Address
First Line	:	2121 W ROSCOE ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-9244
Country	:	US
Telephone Number	:	312-586-1185
Fax Number	:

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

Provider Enumeration Date	:	01/30/2024
Last Update Date	:	01/30/2024

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