MEDICARE: PHYSICALLY PHIT

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	2251S0007X	Sports Physical Therapist		IL

General Provider Information

NPI Number	:	1275706368
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSICALLY PHIT

Provider Business Mailing Address
First Line	:	2320 N DAMEN AVE STE 1R
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-3359
Country	:	US
Telephone Number	:	773-489-0001
Fax Number	:	773-489-0003

Provider Business Practice Location Address
First Line	:	2320 N DAMEN AVE STE 1R
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-3359
Country	:	US
Telephone Number	:	773-489-0001
Fax Number	:	773-489-0003

Authorized Official
Title or Position	:	PHYSICAL THERAPIST
Name	:	POONAM BHARGAVA
Credential	:	P.T.
Telephone Number	:	312-285-1090

Provider Enumeration Date	:	04/09/2008
Last Update Date	:	04/09/2008

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Directions to “PHYSICALLY PHIT ” Practice Location

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