MEDICARE: MISS CASSIE A. DORSEY 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	096002363	IL

General Provider Information

NPI Number	:	1588781439
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS CASSIE A. DORSEY ATC

Provider Business Mailing Address
First Line	:	352 W TEMPLE ST
Second Line	:
City	:	WAVERLY
State	:	IL
Zip	:	62692-1067
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4550 W ILES AVE
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62711
Country	:	US
Telephone Number	:	217-862-0444
Fax Number	:

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

Provider Enumeration Date	:	03/24/2007
Last Update Date	:	08/27/2015

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