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NPI Code Detail

MEDICARE: MRS. BROOKE HAYLEY BISHOP PTA

MEDICARE: MRS. BROOKE HAYLEY BISHOP 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
1225200000XPhysical Therapy Assistant160004229IL

General Provider Information

NPI Number : 1417119504
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. BROOKE HAYLEY BISHOP PTA
Provider Business Mailing Address
First Line : 1208 BERRY ST
Second Line :
City : DENNISON
State : IL
Zip : 62423-2109
Country : US
Telephone Number : 217-463-2572
Fax Number : 217-465-6380
Provider Business Practice Location Address
First Line : 400 W WASHINGTON AVE
Second Line :
City : CHRISMAN
State : IL
Zip : 61924-1042
Country : US
Telephone Number : 217-269-2105
Fax Number : 217-269-2108
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/30/2008
Last Update Date : 06/30/2008

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