MEDICARE: PT WELLNESS

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	2251P0200X	Pediatric Physical Therapist	070010529	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01635329	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1952482515
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PT WELLNESS

Provider Business Mailing Address
First Line	:	1315 N BOSWORTH
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622
Country	:	US
Telephone Number	:	773-203-1314
Fax Number	:	773-395-2215

Provider Business Practice Location Address
First Line	:	1315 N BOSWORTH
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622
Country	:	US
Telephone Number	:	773-203-1314
Fax Number	:	773-395-2215

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. SARA BRIN KARP
Credential	:	MAST OF PHYS THERAPY
Telephone Number	:	773-203-1314

Provider Enumeration Date	:	10/18/2006
Last Update Date	:	07/23/2008

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Directions to “PT WELLNESS ” Practice Location

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