Provider Demographics
NPI:1417060617
Name:TARATSIDES, GEORGE (PT OCS ATL)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:TARATSIDES
Suffix:
Gender:M
Credentials:PT OCS ATL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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:630-759-3251
Practice Address - Street 1:117 ORVILLE ROAD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21221
Practice Address - Country:US
Practice Address - Phone:410-686-2270
Practice Address - Fax:410-686-5447
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16394225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD248167Y5FMedicare PIN