MEDICARE: MRS. KRZYSZTOF KULAGA 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1621716	OTHER	IL	BCBS PROVIDER

General Provider Information

NPI Number	:	1164544060
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KRZYSZTOF KULAGA P.T.

Provider Business Mailing Address
First Line	:	4747 W PETERSON AVE
Second Line	:	SUITE 105
City	:	CHICAGO
State	:	IL
Zip	:	60646-5712
Country	:	US
Telephone Number	:	773-725-8809
Fax Number	:	773-725-4202

Provider Business Practice Location Address
First Line	:	4747 W PETERSON AVE
Second Line	:	SUITE 105
City	:	CHICAGO
State	:	IL
Zip	:	60646-5712
Country	:	US
Telephone Number	:	773-725-8809
Fax Number	:	773-725-4202

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

Provider Enumeration Date	:	04/04/2007
Last Update Date	:	07/08/2007

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