MEDICARE: BRIAN DOMIN 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	070027554	IL

General Provider Information

NPI Number	:	1295429579
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN DOMIN 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	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3436 N LINCOLN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-1173
Country	:	US
Telephone Number	:	773-820-8984
Fax Number	:

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

Provider Enumeration Date	:	06/08/2023
Last Update Date	:	06/08/2023

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