MEDICARE: JERZY DORMAN 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	070009910	IL

General Provider Information

NPI Number	:	1760433106
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERZY DORMAN P.T.

Provider Business Mailing Address
First Line	:	707 LAKE COOK RD
Second Line	:	SUITE 120
City	:	DEERFIELD
State	:	IL
Zip	:	60015-5613
Country	:	US
Telephone Number	:	847-509-0600
Fax Number	:	847-580-1215

Provider Business Practice Location Address
First Line	:	707 LAKE COOK RD
Second Line	:	SUITE 120
City	:	DEERFIELD
State	:	IL
Zip	:	60015-5613
Country	:	US
Telephone Number	:	847-509-0600
Fax Number	:	847-580-1215

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

Provider Enumeration Date	:	05/12/2006
Last Update Date	:	03/22/2017

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