MEDICARE: MR. DAVID FOWKES ATC, MS, FF/PM

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

General Provider Information

NPI Number	:	1043289143
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DAVID FOWKES ATC, MS, FF/PM

Provider Business Mailing Address
First Line	:	1137 SHARI LN
Second Line	:
City	:	LIBERTYVILLE
State	:	IL
Zip	:	60048-2532
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	433 VINE AVE
Second Line	:
City	:	HIGHLAND PARK
State	:	IL
Zip	:	60035-2044
Country	:	US
Telephone Number	:	224-765-2094
Fax Number	:

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

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	07/08/2007

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