MEDICARE: MR. JAMES M TYRRELL ATC, CSCS

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	96001264	IL

General Provider Information

NPI Number	:	1467449314
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAMES M TYRRELL ATC, CSCS

Provider Business Mailing Address
First Line	:	4447 N MALDEN ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-5683
Country	:	US
Telephone Number	:	773-561-1301
Fax Number	:

Provider Business Practice Location Address
First Line	:	1323 W DIVERSEY PKWY
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-1207
Country	:	US
Telephone Number	:	773-549-2520
Fax Number	:

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

Provider Enumeration Date	:	10/04/2005
Last Update Date	:	07/08/2007

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