Provider Demographics
NPI:1114036761
Name:KOESTERER, JULIE SUDDUTH (PT)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:SUDDUTH
Last Name:KOESTERER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 EDEN PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:SHILOH
Mailing Address - State:IL
Mailing Address - Zip Code:62269-2999
Mailing Address - Country:US
Mailing Address - Phone:618-624-0960
Mailing Address - Fax:
Practice Address - Street 1:1901 FRANK SCOTT PKWY E
Practice Address - Street 2:
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-7296
Practice Address - Country:US
Practice Address - Phone:618-624-7077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070-006771OtherLICENSE #