Provider Demographics
NPI:1114036860
Name:MUSKOPF, KURT JON (OTRIL CHT)
Entity Type:Individual
Prefix:MR
First Name:KURT
Middle Name:JON
Last Name:MUSKOPF
Suffix:
Gender:M
Credentials:OTRIL CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 APEX DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249-1282
Mailing Address - Country:US
Mailing Address - Phone:618-651-0444
Mailing Address - Fax:
Practice Address - Street 1:5900 N ILLINOIS
Practice Address - Street 2:STE 9
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208
Practice Address - Country:US
Practice Address - Phone:314-621-1416
Practice Address - Fax:618-624-9330
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056006024225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK06800Medicare ID - Type Unspecified