MEDICARE: ERIN FASULA PT, MPT

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	070016144	IL

General Provider Information

NPI Number	:	1598949109
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIN FASULA PT, MPT

Provider Business Mailing Address
First Line	:	600 OAKMONT LN STE 600C
Second Line	:
City	:	WESTMONT
State	:	IL
Zip	:	60559-5548
Country	:	US
Telephone Number	:	630-575-6250
Fax Number	:

Provider Business Practice Location Address
First Line	:	7474 E STATE ST
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61108-2644
Country	:	US
Telephone Number	:	158-397-4439
Fax Number	:	815-397-4459

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

Provider Enumeration Date	:	12/19/2007
Last Update Date	:	04/03/2018

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