MEDICARE: MARK PROBASCO 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	15209	WI

General Provider Information

NPI Number	:	1356709190
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK PROBASCO DPT

Provider Business Mailing Address
First Line	:	2001 BUTTERFIELD RD STE 1600
Second Line	:
City	:	DOWNERS GROVE
State	:	IL
Zip	:	60515-1211
Country	:	US
Telephone Number	:	866-370-8206
Fax Number	:

Provider Business Practice Location Address
First Line	:	727 W JOHNSON ST
Second Line	:
City	:	FOND DU LAC
State	:	WI
Zip	:	54935-2015
Country	:	US
Telephone Number	:	920-581-0111
Fax Number	:

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

Provider Enumeration Date	:	02/08/2016
Last Update Date	:	12/06/2024

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Directions to “ MARK PROBASCO DPT” Practice Location

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