MEDICARE: MS. TINA M PAULEY 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

General Provider Information

NPI Number	:	1518014687
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TINA M PAULEY ATC

Provider Business Mailing Address
First Line	:	5440 FOSTER ST.
Second Line	:
City	:	SKOKIE
State	:	IL
Zip	:	60077
Country	:	US
Telephone Number	:	630-928-3400
Fax Number	:

Provider Business Practice Location Address
First Line	:	1031 N CLARK ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60610-2809
Country	:	US
Telephone Number	:	312-951-9700
Fax Number	:

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

Provider Enumeration Date	:	01/04/2007
Last Update Date	:	07/08/2007

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