MEDICARE: MR. MICHAEL ANTHONY GALVAN JR. ATC

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	096-001139	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	096-001139	OTHER	IL	LICENSE

General Provider Information

NPI Number	:	1437143252
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL ANTHONY GALVAN JR. ATC

Provider Business Mailing Address
First Line	:	1225 W 31ST ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-5507
Country	:	US
Telephone Number	:	312-437-0080
Fax Number	:

Provider Business Practice Location Address
First Line	:	1225 W 31ST ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-5507
Country	:	US
Telephone Number	:	312-437-0080
Fax Number	:

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

Provider Enumeration Date	:	09/07/2005
Last Update Date	:	03/02/2024

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