Provider Demographics
NPI:1043289168
Name:KOSTER, GRANT RYAN (PT, MSPT, ATC, CSCS)
Entity Type:Individual
Prefix:MR
First Name:GRANT
Middle Name:RYAN
Last Name:KOSTER
Suffix:
Gender:M
Credentials:PT, MSPT, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8813
Mailing Address - Country:US
Mailing Address - Phone:630-575-6250
Mailing Address - Fax:630-575-7450
Practice Address - Street 1:6000 W. TOUHY
Practice Address - Street 2:SUITE 202
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646
Practice Address - Country:US
Practice Address - Phone:773-774-4291
Practice Address - Fax:773-774-4527
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096-001522174400000X
IL070012664225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist