MEDICARE: MR. TIMOTHY DALE KISNER M.P.T.

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	070-011706	IL

General Provider Information

NPI Number	:	1689650004
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TIMOTHY DALE KISNER M.P.T.

Provider Business Mailing Address
First Line	:	205 W WACKER DR
Second Line	:	SUITE 1020
City	:	CHICAGO
State	:	IL
Zip	:	60606-1216
Country	:	US
Telephone Number	:	312-640-0329
Fax Number	:

Provider Business Practice Location Address
First Line	:	4700 GILBERT AVE
Second Line	:	SUITE 43A
City	:	WESTERN SPRINGS
State	:	IL
Zip	:	60558-1753
Country	:	US
Telephone Number	:	708-783-1044
Fax Number	:	708-783-1048

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

Provider Enumeration Date	:	12/16/2005
Last Update Date	:	08/13/2014

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