MEDICARE: ALI N GRAHAM 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	2255A2300X	Athletic Trainer
2	390200000X	Student in an Organized Health Care Education/Training Program
3	225100000X	Physical Therapist	070-025436	IL

General Provider Information

NPI Number	:	1215462130
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALI N GRAHAM DPT

Provider Business Mailing Address
First Line	:	2122 YORK RD STE 300
Second Line	:
City	:	OAK BROOK
State	:	IL
Zip	:	60523-1925
Country	:	US
Telephone Number	:	630-575-1980
Fax Number	:

Provider Business Practice Location Address
First Line	:	20 N MICHIGAN AVE LBBY 103
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60602-4817
Country	:	US
Telephone Number	:	312-236-0660
Fax Number	:	312-236-1219

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

Provider Enumeration Date	:	04/28/2017
Last Update Date	:	10/14/2021

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