MEDICARE: JORDAN THIEME

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	225100000X	Physical Therapist	070021886	IL

General Provider Information

NPI Number	:	1972972578
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN THIEME

Provider Business Mailing Address
First Line	:	625 ENTERPRISE DR
Second Line	:
City	:	OAK BROOK
State	:	IL
Zip	:	60523-8813
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5230 S BLACKSTONE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60615-4106
Country	:	US
Telephone Number	:	773-256-1475
Fax Number	:

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

Provider Enumeration Date	:	09/24/2015
Last Update Date	:	11/16/2015

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