MEDICARE: PATRICK PALSGROVE 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	1738	CO
2	363AM0700X	Medical Physician Assistant	085.002878	IL

General Provider Information

NPI Number	:	1457494148
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICK PALSGROVE PA-C

Provider Business Mailing Address
First Line	:	2649 N LARAMIE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639-1613
Country	:	US
Telephone Number	:	773-237-1411
Fax Number	:	773-237-1412

Provider Business Practice Location Address
First Line	:	2649 N LARAMIE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639-1613
Country	:	US
Telephone Number	:	773-237-1411
Fax Number	:	773-237-1412

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

Provider Enumeration Date	:	02/14/2007
Last Update Date	:	11/17/2011

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Directions to “ PATRICK PALSGROVE PA-C” Practice Location

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