MEDICARE: R.A. PHYSICAL THERAPY, PC

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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174578157
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	R.A. PHYSICAL THERAPY, PC

Provider Business Mailing Address
First Line	:	109 N SANGAMON AVE
Second Line	:
City	:	GIBSON CITY
State	:	IL
Zip	:	60936-1342
Country	:	US
Telephone Number	:	217-784-8033
Fax Number	:	217-784-8077

Provider Business Practice Location Address
First Line	:	109 N SANGAMON AVE
Second Line	:
City	:	GIBSON CITY
State	:	IL
Zip	:	60936-1342
Country	:	US
Telephone Number	:	217-784-8033
Fax Number	:	217-784-8077

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RHODORA BAUTISTA ASTRONOMO
Credential	:	PT
Telephone Number	:	217-784-8033

Provider Enumeration Date	:	05/24/2006
Last Update Date	:	04/20/2008

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