Provider Demographics
NPI:1073145561
Name:KISTENFEGER, GARY JOSEPH (PT)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:JOSEPH
Last Name:KISTENFEGER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 MIDTOWN RD
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IL
Mailing Address - Zip Code:61354-1269
Mailing Address - Country:US
Mailing Address - Phone:815-223-8600
Mailing Address - Fax:
Practice Address - Street 1:1400 MIDTOWN RD
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-1269
Practice Address - Country:US
Practice Address - Phone:815-223-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.005952225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist