MEDICARE: DEREK WALTER MIGAZZI

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	5501011921	MI

General Provider Information

NPI Number	:	1699950808
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEREK WALTER MIGAZZI

Provider Business Mailing Address
First Line	:	790 REMINGTON BLVD
Second Line	:
City	:	BOLINGBROOK
State	:	IL
Zip	:	60440-4909
Country	:	US
Telephone Number	:	630-296-2223
Fax Number	:

Provider Business Practice Location Address
First Line	:	1110 HAMMOND RD E
Second Line	:	STE 5
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49686-9362
Country	:	US
Telephone Number	:	231-995-5210
Fax Number	:

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

Provider Enumeration Date	:	01/07/2008
Last Update Date	:	04/09/2014

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