MEDICARE: CLARE E KENNEDY 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	225100000X	Physical Therapist	070017245	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1633794	OTHER		BCBS OF ILLINOIS

General Provider Information

NPI Number	:	1154551208
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLARE E KENNEDY DPT

Provider Business Mailing Address
First Line	:	625 ENTERPRISE DR
Second Line	:
City	:	OAK BROOK
State	:	IL
Zip	:	60523-8813
Country	:	US
Telephone Number	:	630-575-6250
Fax Number	:

Provider Business Practice Location Address
First Line	:	2500 W 94TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60805-2818
Country	:	US
Telephone Number	:	773-233-9570
Fax Number	:

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

Provider Enumeration Date	:	07/23/2009
Last Update Date	:	12/19/2017

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Directions to “ CLARE E KENNEDY DPT” Practice Location

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