Provider Demographics
NPI:1144353350
Name:COLE, KEITH ROBERT (DPT)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:ROBERT
Last Name:COLE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4050 N SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-2081
Mailing Address - Country:US
Mailing Address - Phone:319-331-8513
Mailing Address - Fax:855-588-2530
Practice Address - Street 1:4050 N SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-2081
Practice Address - Country:US
Practice Address - Phone:319-331-8513
Practice Address - Fax:855-588-2530
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070015612225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK39223Medicare PIN