MEDICARE: MICHAEL CERNIVEC OTR/L

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	225XH1200X	Hand Occupational Therapist	056.012880	IL

General Provider Information

NPI Number	:	1306403076
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL CERNIVEC OTR/L

Provider Business Mailing Address
First Line	:	730 BEACON DR
Second Line	:
City	:	LAKE BARRINGTON
State	:	IL
Zip	:	60010-1577
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1009 STATE ROUTE 22
Second Line	:
City	:	FOX RIVER GROVE
State	:	IL
Zip	:	60021-1998
Country	:	US
Telephone Number	:	847-462-8707
Fax Number	:

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

Provider Enumeration Date	:	05/28/2019
Last Update Date	:	05/28/2019

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