MEDICARE: MR. KEVIN MICHAEL PENNINGTON 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		IL

General Provider Information

NPI Number	:	1487629903
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KEVIN MICHAEL PENNINGTON ATC

Provider Business Mailing Address
First Line	:	953 AUDUBON LN
Second Line	:
City	:	AURORA
State	:	IL
Zip	:	60506-8852
Country	:	US
Telephone Number	:	630-896-2711
Fax Number	:

Provider Business Practice Location Address
First Line	:	296 RANDALL RD
Second Line	:
City	:	GENEVA
State	:	IL
Zip	:	60134-4203
Country	:	US
Telephone Number	:	630-208-4215
Fax Number	:	630-208-5507

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

Provider Enumeration Date	:	02/19/2006
Last Update Date	:	07/08/2007

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