MEDICARE: CHRISTOPHER TRIPP PROCTOR ATC

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

General Provider Information

NPI Number	:	1972747459
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTOPHER TRIPP PROCTOR ATC

Provider Business Mailing Address
First Line	:	303 S COMMERCIAL ST
Second Line	:	SUITE 10
City	:	HARRISBURG
State	:	IL
Zip	:	62946-2125
Country	:	US
Telephone Number	:	618-252-5555
Fax Number	:	618-252-2279

Provider Business Practice Location Address
First Line	:	303 S COMMERCIAL ST
Second Line	:	SUITE 10
City	:	HARRISBURG
State	:	IL
Zip	:	62946-2125
Country	:	US
Telephone Number	:	618-252-5555
Fax Number	:	618-252-2279

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

Provider Enumeration Date	:	04/28/2009
Last Update Date	:	01/13/2014

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