MEDICARE: DR. THEODORE J GALVANI JR. MD

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	207P00000X	Emergency Medicine Physician	25260	WI
2	207P00000X	Emergency Medicine Physician	036-089612	IL

General Provider Information

NPI Number	:	1801901814
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THEODORE J GALVANI JR. MD

Provider Business Mailing Address
First Line	:	3021 FALLING WATERS BLVD
Second Line	:	SUITE A
City	:	LINDENHURST
State	:	IL
Zip	:	60046-6793
Country	:	US
Telephone Number	:	847-356-9300
Fax Number	:	847-356-7260

Provider Business Practice Location Address
First Line	:	3021 FALLING WATERS BLVD
Second Line	:	SUITE A
City	:	LINDENHURST
State	:	IL
Zip	:	60046-6793
Country	:	US
Telephone Number	:	847-356-9300
Fax Number	:	847-356-7260

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

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	03/12/2010

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