MEDICARE: BRIDGEPORT PHYSICAL WELLNESS LLC

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	261QP2000X	Physical Therapy Clinic/Center
2	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1679443600
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDGEPORT PHYSICAL WELLNESS LLC

Provider Business Mailing Address
First Line	:	702 W 31ST ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-3007
Country	:	US
Telephone Number	:	312-375-2802
Fax Number	:

Provider Business Practice Location Address
First Line	:	702 W 31ST ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-3007
Country	:	US
Telephone Number	:	312-375-2802
Fax Number	:

Authorized Official
Title or Position	:	PHYSICAL THERAPIST
Name	:	AKSHAYA MAHESH
Credential	:	PT, DPT
Telephone Number	:	312-375-2802

Provider Enumeration Date	:	11/05/2025
Last Update Date	:	05/19/2026

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