MEDICARE: MRS. BRIDGET L JOHNSON PT OCS

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	225100000X	Physical Therapist	070011438	IL

General Provider Information

NPI Number	:	1568557189
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BRIDGET L JOHNSON PT OCS

Provider Business Mailing Address
First Line	:	1640 MELUGINS GROVE ROAD
Second Line	:
City	:	STEWARD
State	:	IL
Zip	:	60553
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	404 W BLACKHAWK DRIVE
Second Line	:	SUITE 1U
City	:	BYRON
State	:	IL
Zip	:	61010
Country	:	US
Telephone Number	:	815-234-5561
Fax Number	:	815-234-5870

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

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	04/29/2008

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