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NPI Code Detail

MEDICARE: MRS. KATHLEEN ANN ILLIG PTA

MEDICARE: MRS. KATHLEEN ANN ILLIG PTA
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
1225200000XPhysical Therapy AssistantPTA 0000003466TN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
13077388OTHERTNBCBS PROVIDER NUMBER

General Provider Information

NPI Number : 1750458394
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. KATHLEEN ANN ILLIG PTA
Provider Business Mailing Address
First Line : 6655 QUINCE RD STE 101
Second Line :
City : MEMPHIS
State : TN
Zip : 38119-8031
Country : US
Telephone Number : 901-755-9988
Fax Number : 901-755-2233
Provider Business Practice Location Address
First Line : 6655 QUINCE RD STE 101
Second Line :
City : MEMPHIS
State : TN
Zip : 38119-8031
Country : US
Telephone Number : 901-755-9988
Fax Number : 901-755-2233
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/29/2006
Last Update Date : 07/08/2007

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