MEDICARE: KONRAD RICHARD KOCZWARA 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	070.022449	IL

General Provider Information

NPI Number	:	1780129825
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KONRAD RICHARD KOCZWARA P.T.

Provider Business Mailing Address
First Line	:	8036 W BERWYN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60656-1502
Country	:	US
Telephone Number	:	773-510-4312
Fax Number	:

Provider Business Practice Location Address
First Line	:	1115 W ARMITAGE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-4103
Country	:	US
Telephone Number	:	773-510-4312
Fax Number	:

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

Provider Enumeration Date	:	12/28/2016
Last Update Date	:	12/28/2016

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