Provider Demographics
NPI:1154484368
Name:MICHAEL THOMAS SHOEMAKE
Entity Type:Organization
Organization Name:MICHAEL THOMAS SHOEMAKE
Other - Org Name:MOMENTUM PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:SHOEMAKE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:847-996-0650
Mailing Address - Street 1:1017 W PARK AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-2502
Mailing Address - Country:US
Mailing Address - Phone:847-996-0650
Mailing Address - Fax:815-385-5753
Practice Address - Street 1:1017 W PARK AVE
Practice Address - Street 2:SUITE B
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-2502
Practice Address - Country:US
Practice Address - Phone:847-997-0650
Practice Address - Fax:815-385-5753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214486Medicare ID - Type Unspecified