MEDICARE: MR. GAMAL RIAD IBRAHIM PHYSICAL THERAPIST

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	174400000X	Specialist		IL

General Provider Information

NPI Number	:	1922270099
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GAMAL RIAD IBRAHIM PHYSICAL THERAPIST

Provider Business Mailing Address
First Line	:	3400 W 111TH ST
Second Line	:	#158
City	:	CHICAGO
State	:	IL
Zip	:	60655-3330
Country	:	US
Telephone Number	:	708-566-0816
Fax Number	:	708-233-0341

Provider Business Practice Location Address
First Line	:	6322 S PULASKI RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60629-4706
Country	:	US
Telephone Number	:	708-566-0816
Fax Number	:	708-233-0341

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

Provider Enumeration Date	:	03/29/2008
Last Update Date	:	03/31/2008

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