Provider Demographics
NPI:1407088453
Name:FASSEAS, MEGHAN LIVELY
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:LIVELY
Last Name:FASSEAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MEGHAN
Other - Middle Name:
Other - Last Name:LIVELY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:5616 W 63RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638-5511
Practice Address - Country:US
Practice Address - Phone:773-526-5239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-10
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.017272225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00973765OtherMEDICARE RAILROAD
ILP00776865OtherMEDICARE RR
IL216859069Medicare PIN
ILP00776865OtherMEDICARE RR