MEDICARE: MR. CODY CONRAD MERRILL PTA

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	225200000X	Physical Therapy Assistant	160008092	IL

General Provider Information

NPI Number	:	1356042386
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CODY CONRAD MERRILL PTA

Provider Business Mailing Address
First Line	:	405 DEVONSHIRE ST
Second Line	:
City	:	DIXON
State	:	IL
Zip	:	61021-1116
Country	:	US
Telephone Number	:	815-441-9965
Fax Number	:

Provider Business Practice Location Address
First Line	:	811 S 10TH ST
Second Line	:
City	:	OREGON
State	:	IL
Zip	:	61061-2129
Country	:	US
Telephone Number	:	815-732-7994
Fax Number	:

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

Provider Enumeration Date	:	03/16/2023
Last Update Date	:	03/16/2023

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