MEDICARE: MATTHEW ALLEN PTACK PA-C

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	363A00000X	Physician Assistant	085006139	IL
2	363AS0400X	Surgical Physician Assistant	085006139	IL

General Provider Information

NPI Number	:	1356880470
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW ALLEN PTACK PA-C

Provider Business Mailing Address
First Line	:	2650 RIDGE AVE. SUITE 1223
Second Line	:
City	:	SKOKIE
State	:	IL
Zip	:	60076-1214
Country	:	US
Telephone Number	:	847-866-7846
Fax Number	:	866-954-5787

Provider Business Practice Location Address
First Line	:	9650 GROSS POINT RD STE 2900
Second Line	:
City	:	SKOKIE
State	:	IL
Zip	:	60076
Country	:	US
Telephone Number	:	847-866-7846
Fax Number	:	866-954-5787

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

Provider Enumeration Date	:	02/22/2017
Last Update Date	:	02/18/2026

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Directions to “ MATTHEW ALLEN PTACK PA-C” Practice Location

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