MEDICARE: MRS. MARI JO PESAVENTO

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	:	1164477626
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARI JO PESAVENTO

Provider Business Mailing Address
First Line	:	3417 WEST 115TH PLACE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60655
Country	:	US
Telephone Number	:	773-445-8604
Fax Number	:	773-239-9747

Provider Business Practice Location Address
First Line	:	3417 WEST 115TH PLACE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60655-3622
Country	:	US
Telephone Number	:	773-445-8604
Fax Number	:	773-239-9747

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

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	07/21/2022

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