MEDICARE: MR. AIDAN MARTIN BRODIE COTA

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	224Z00000X	Occupational Therapy Assistant	057.004681	IL

General Provider Information

NPI Number	:	1164953659
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. AIDAN MARTIN BRODIE COTA

Provider Business Mailing Address
First Line	:	10325 KERRY RIDGE CT
Second Line	:
City	:	CHICAGO RIDGE
State	:	IL
Zip	:	60415-2390
Country	:	US
Telephone Number	:	708-655-3179
Fax Number	:

Provider Business Practice Location Address
First Line	:	10325 KERRY RIDGE CT
Second Line	:
City	:	CHICAGO RIDGE
State	:	IL
Zip	:	60415-2390
Country	:	US
Telephone Number	:	708-655-3179
Fax Number	:

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

Provider Enumeration Date	:	03/25/2017
Last Update Date	:	03/25/2017

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