Provider Demographics
NPI:1003969619
Name:RATHJEN, MARK T (DPT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:RATHJEN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17660 WRIGHT STREET
Mailing Address - Street 2:SUITES 9/10
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130
Mailing Address - Country:US
Mailing Address - Phone:402-933-4027
Mailing Address - Fax:402-933-5027
Practice Address - Street 1:17660 WRIGHT STREET
Practice Address - Street 2:SUITES 9/10
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130
Practice Address - Country:US
Practice Address - Phone:402-933-4027
Practice Address - Fax:402-933-5027
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE24942251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025429200Medicaid
NE10025429000Medicaid
NE10025429300Medicaid
NE10025428900Medicaid
02170OtherBCBS
NE10025429100Medicaid
P00399934Medicare PIN
280472Medicare PIN