MEDICARE: TRAVIS J SPAGNOLA

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	070016338	IL

General Provider Information

NPI Number	:	1992978175
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRAVIS J SPAGNOLA

Provider Business Mailing Address
First Line	:	1816 170TH ST
Second Line	:
City	:	HAZEL CREST
State	:	IL
Zip	:	60429-1451
Country	:	US
Telephone Number	:	708-335-1415
Fax Number	:	708-335-0115

Provider Business Practice Location Address
First Line	:	17236 HARLEM AVE
Second Line	:
City	:	TINLEY PARK
State	:	IL
Zip	:	60477-6619
Country	:	US
Telephone Number	:	708-633-8379
Fax Number	:	708-633-8614

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

Provider Enumeration Date	:	04/08/2008
Last Update Date	:	05/02/2008

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