MEDICARE: MRS. DIANE RUTH GENAZE 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		IL

General Provider Information

NPI Number	:	1104981588
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DIANE RUTH GENAZE P.T.

Provider Business Mailing Address
First Line	:	3901 CLAUSEN AVE
Second Line	:
City	:	WESTERN SPRINGS
State	:	IL
Zip	:	60558-1226
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	710 S PAULINA ST
Second Line	:	SUITE 732
City	:	CHICAGO
State	:	IL
Zip	:	60612-3808
Country	:	US
Telephone Number	:	312-942-5661
Fax Number	:

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

Provider Enumeration Date	:	12/26/2006
Last Update Date	:	07/08/2007

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