MEDICARE: RACHELLE KELLY PORATH PT

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	5501010799	MI
2	225100000X	Physical Therapist	P16594	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	650B110390	OTHER	MI	BCBS

General Provider Information

NPI Number	:	1619065596
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RACHELLE KELLY PORATH PT

Provider Business Mailing Address
First Line	:	2122 YORK RD STE 300
Second Line	:
City	:	OAK BROOK
State	:	IL
Zip	:	60523-1925
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	166 SPRINGBROOK AVE STE 201
Second Line	:
City	:	CLAYTON
State	:	NC
Zip	:	27520-8520
Country	:	US
Telephone Number	:	919-535-8461
Fax Number	:

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

Provider Enumeration Date	:	10/10/2006
Last Update Date	:	12/20/2024

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Directions to “ RACHELLE KELLY PORATH PT” Practice Location

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