MEDICARE: SPENCER FANG PT, DPT

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	208100000X	Physical Medicine & Rehabilitation Physician	070024872	IL

General Provider Information

NPI Number	:	1114564135
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SPENCER FANG PT, DPT

Provider Business Mailing Address
First Line	:	1824 JOHNS DR
Second Line	:
City	:	GLENVIEW
State	:	IL
Zip	:	60025-1657
Country	:	US
Telephone Number	:	847-581-6300
Fax Number	:

Provider Business Practice Location Address
First Line	:	1824 JOHNS DR
Second Line	:
City	:	GLENVIEW
State	:	IL
Zip	:	60025-1657
Country	:	US
Telephone Number	:	847-581-6300
Fax Number	:

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

Provider Enumeration Date	:	12/09/2019
Last Update Date	:	12/19/2019

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