MEDICARE: TIMOTHY ROBERT LADEWIG

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	390200000X	Student in an Organized Health Care Education/Training Program
2	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1780399147
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY ROBERT LADEWIG

Provider Business Mailing Address
First Line	:	50 CARRIAGE TRL
Second Line	:
City	:	PALOS HEIGHTS
State	:	IL
Zip	:	60463-1222
Country	:	US
Telephone Number	:	708-541-8937
Fax Number	:

Provider Business Practice Location Address
First Line	:	50 CARRIAGE TRL
Second Line	:
City	:	PALOS HEIGHTS
State	:	IL
Zip	:	60463-1222
Country	:	US
Telephone Number	:	708-541-8937
Fax Number	:

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

Provider Enumeration Date	:	01/20/2023
Last Update Date	:	01/20/2023

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