Provider Demographics
NPI:1134133515
Name:METTERNICH, STEVEN GLEN (PT)
Entity Type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:GLEN
Last Name:METTERNICH
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 1:3655 E MIRROR LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47805-2138
Mailing Address - Country:US
Mailing Address - Phone:812-645-4071
Mailing Address - Fax:866-920-2133
Practice Address - Street 1:3655 E MIRROR LAKE AVE
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47805-2138
Practice Address - Country:US
Practice Address - Phone:812-645-4071
Practice Address - Fax:866-920-2133
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070002318225100000X
IN05001152A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001283001OtherBLUE CROSS BLUE SHIELD
IL650005686OtherRAILROAD MEDICARE UPIN
IL000-1232012OtherBLUE CROSS-KINTIC-INDIVIDUAL
IL356107600OtherUS DEPT OF LABOR
IL1232012OtherBLUE CROSS 2010 KINETIC
IL001541OtherHEALTH ALLIANCE
IL010934666OtherKINETIC TAX ID
IL001541OtherHEALTH ALLIANCE
IL351659241OtherOLD TAX ID NUMBER
IL351659241OtherOLD TAX ID NUMBER
IL0001283001OtherBLUE CROSS BLUE SHIELD
IL215142Medicare PIN
IL650005686OtherRAILROAD MEDICARE UPIN
IL010934666OtherKINETIC TAX ID
ILK39693Medicare UPIN