MEDICARE: LEE DAVIMES P.T.

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	C0000158	IL
2	225100000X	Physical Therapist	070008788	IL

General Provider Information

NPI Number	:	1043434871
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEE DAVIMES P.T.

Provider Business Mailing Address
First Line	:	205 W WACKER DR
Second Line	:	SUITE 1020
City	:	CHICAGO
State	:	IL
Zip	:	60606-1216
Country	:	US
Telephone Number	:	312-640-0329
Fax Number	:	312-640-0407

Provider Business Practice Location Address
First Line	:	1629 CHICAGO AVE
Second Line	:
City	:	EVANSTON
State	:	IL
Zip	:	60201-4504
Country	:	US
Telephone Number	:	847-475-1630
Fax Number	:	847-475-1631

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

Provider Enumeration Date	:	04/12/2007
Last Update Date	:	12/02/2011

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