Provider Demographics
NPI:1417107194
Name:SPARACINO, PHILLIP M (PT,DPT,OCS)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:M
Last Name:SPARACINO
Suffix:
Gender:M
Credentials:PT,DPT,OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 W WACKER DR
Mailing Address - Street 2:SUITE 1020
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-1216
Mailing Address - Country:US
Mailing Address - Phone:312-640-0329
Mailing Address - Fax:312-640-0407
Practice Address - Street 1:13614 CICERO AVE
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:IL
Practice Address - Zip Code:60445-1937
Practice Address - Country:US
Practice Address - Phone:708-389-3077
Practice Address - Fax:708-389-3545
Is Sole Proprietor?:No
Enumeration Date:2008-09-30
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.001685225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILR03891Medicare UPIN
IL204585001Medicare PIN