MEDICARE: TARAH ELLINGTON MED, ATC, CSCS,

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	2255A2300X	Athletic Trainer	096003007	IL

General Provider Information

NPI Number	:	1962781377
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARAH ELLINGTON MED, ATC, CSCS,

Provider Business Mailing Address
First Line	:	5700 COLLEGE RD
Second Line	:
City	:	LISLE
State	:	IL
Zip	:	60532-2851
Country	:	US
Telephone Number	:	630-829-6154
Fax Number	:	630-829-6169

Provider Business Practice Location Address
First Line	:	5700 COLLEGE RD
Second Line	:
City	:	LISLE
State	:	IL
Zip	:	60532-2851
Country	:	US
Telephone Number	:	630-829-6154
Fax Number	:	630-829-6169

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

Provider Enumeration Date	:	08/16/2011
Last Update Date	:	08/16/2011

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