MEDICARE: ALYSSA ANDERSON 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	096.003867	IL
2	2255A2300X	Athletic Trainer	AT. 003883	OH

General Provider Information

NPI Number	:	1972968329
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALYSSA ANDERSON ATC

Provider Business Mailing Address
First Line	:	3225 W FOSTER AVE
Second Line	:	BOX 25
City	:	CHICAGO
State	:	IL
Zip	:	60625-4823
Country	:	US
Telephone Number	:	773-244-6221
Fax Number	:

Provider Business Practice Location Address
First Line	:	3225 W FOSTER AVE
Second Line	:	BOX 25
City	:	CHICAGO
State	:	IL
Zip	:	60625-4823
Country	:	US
Telephone Number	:	773-244-6221
Fax Number	:

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

Provider Enumeration Date	:	12/29/2015
Last Update Date	:	12/29/2015

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