MEDICARE: PHOENIX UNDERGROUND PHYSICAL THERAPY LLC

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	261QP2000X	Physical Therapy Clinic/Center	070018695	IL

General Provider Information

NPI Number	:	1811358849
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENIX UNDERGROUND PHYSICAL THERAPY LLC

Provider Business Mailing Address
First Line	:	1142 W NORTH SHORE AVE APT 3N
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60626-4640
Country	:	US
Telephone Number	:	608-217-6841
Fax Number	:

Provider Business Practice Location Address
First Line	:	1142 W NORTH SHORE AVE APT 3N
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60626-4640
Country	:	US
Telephone Number	:	608-217-6841
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MATTHEW MCGUIRE
Credential	:	DPT
Telephone Number	:	608-217-6841

Provider Enumeration Date	:	03/18/2016
Last Update Date	:	03/18/2016

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