MEDICARE: FETCH PHYSICAL THERAPY 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

General Provider Information

NPI Number	:	1689327827
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FETCH PHYSICAL THERAPY LLC

Provider Business Mailing Address
First Line	:	1800 W DIVERSEY PKWY APT O
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-1039
Country	:	US
Telephone Number	:	847-212-1560
Fax Number	:

Provider Business Practice Location Address
First Line	:	1800 W DIVERSEY PKWY APT O
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-1039
Country	:	US
Telephone Number	:	847-212-1560
Fax Number	:

Authorized Official
Title or Position	:	PHYSICAL THERAPIST/OWNER
Name	:	AMY J FETCH
Credential	:	DPT
Telephone Number	:	847-212-1560

Provider Enumeration Date	:	01/28/2022
Last Update Date	:	01/28/2022

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