MEDICARE: EDIN ALIC

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	2255A2300X	Athletic Trainer		IL

General Provider Information

NPI Number	:	1427830074
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDIN ALIC

Provider Business Mailing Address
First Line	:	5050 E STATE ST
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61108-2311
Country	:	US
Telephone Number	:	773-757-3454
Fax Number	:

Provider Business Practice Location Address
First Line	:	5050 E STATE ST
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61108-2311
Country	:	US
Telephone Number	:	773-757-3454
Fax Number	:

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

Provider Enumeration Date	:	10/18/2023
Last Update Date	:	01/26/2024

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Directions to “ EDIN ALIC ” Practice Location

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