Basic Information
| Provider Information | |||||||||
| NPI: | 1497795629 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONWAY | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EVANS | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | G | ||||||||
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| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1119 | ||||||||
| Address2: | |||||||||
| City: | MATTESON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604434119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087475850 | ||||||||
| FaxNumber: | 7087479991 | ||||||||
| Practice Location | |||||||||
| Address1: | 71 W 156TH ST | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | HARVEY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604264260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083313748 | ||||||||
| FaxNumber: | 7083313605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 01/21/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070005954 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.