MEDICARE: JAMES M BANSBERG 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	070-020334	IL

General Provider Information

NPI Number	:	1205263654
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES M BANSBERG DPT

Provider Business Mailing Address
First Line	:	1953 N CLYBOURN AVE
Second Line	:	UNIT S
City	:	CHICAGO
State	:	IL
Zip	:	60614-4945
Country	:	US
Telephone Number	:	773-871-3100
Fax Number	:	773-871-7388

Provider Business Practice Location Address
First Line	:	1953 N CLYBOURN AVE
Second Line	:	UNIT S
City	:	CHICAGO
State	:	IL
Zip	:	60614-4945
Country	:	US
Telephone Number	:	773-871-3100
Fax Number	:	773-871-7388

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

Provider Enumeration Date	:	10/01/2013
Last Update Date	:	10/01/2013

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