MEDICARE: MRS. MELANIE LINDA AHLGRIM

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	:	1538136593
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MELANIE LINDA AHLGRIM

Provider Business Mailing Address
First Line	:	6023 N NEWBURG AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60631-2617
Country	:	US
Telephone Number	:	773-775-0349
Fax Number	:

Provider Business Practice Location Address
First Line	:	6000 N TOUHY
Second Line	:	SUITE 202
City	:	CHICAGO
State	:	IL
Zip	:	60646
Country	:	US
Telephone Number	:	773-774-4291
Fax Number	:

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

Provider Enumeration Date	:	03/08/2006
Last Update Date	:	07/08/2007

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