Provider Demographics
NPI:1558485342
Name:TULAYBA, ALWAYNE S (PT)
Entity Type:Individual
Prefix:MR
First Name:ALWAYNE
Middle Name:S
Last Name:TULAYBA
Suffix:
Gender:M
Credentials:PT
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Other - First Name:
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Mailing Address - Street 1:6135 N BROADWAY ST
Mailing Address - Street 2:# 301
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-2553
Mailing Address - Country:US
Mailing Address - Phone:773-405-0130
Mailing Address - Fax:773-764-6197
Practice Address - Street 1:6135 N BROADWAY ST
Practice Address - Street 2:# 301
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-2553
Practice Address - Country:US
Practice Address - Phone:773-405-0130
Practice Address - Fax:773-764-6197
Is Sole Proprietor?:No
Enumeration Date:2007-03-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL205042Medicare PIN