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NPI Code Detail

MEDICARE: MR. JOMON M EDAKARA

MEDICARE: MR. JOMON M EDAKARA
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
1225100000XPhysical Therapist05008369AIN

General Provider Information

NPI Number : 1609094630
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. JOMON M EDAKARA
Provider Business Mailing Address
First Line : 1313 HALLBERG LN
Second Line :
City : PARKRIDGE
State : IL
Zip : 60068
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1551 LAKE COOK RD
Second Line :
City : DEERFIELD
State : IL
Zip : 60015-5651
Country : US
Telephone Number : 847-374-0500
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/23/2007
Last Update Date : 08/13/2024

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Directions to “ MR. JOMON M EDAKARA ” Practice Location

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