Provider Demographics
NPI:1164627485
Name:XAVIER, MARIO SEBASTIN (MHS, PT)
Entity Type:Individual
Prefix:MR
First Name:MARIO
Middle Name:SEBASTIN
Last Name:XAVIER
Suffix:
Gender:M
Credentials:MHS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 S MICHIGAN AVE APT 2015
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-2320
Mailing Address - Country:US
Mailing Address - Phone:317-285-8154
Mailing Address - Fax:
Practice Address - Street 1:1130 SOUTH MICHGAN AVE, APT# 2015
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605
Practice Address - Country:US
Practice Address - Phone:317-285-8154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05008916A225100000X
IL070-016163225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211585033Medicare PIN
IL216859053Medicare PIN