Provider Demographics
NPI:1164435657
Name:STADT, RAYMOND JEROME (ATC)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:JEROME
Last Name:STADT
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20032 S MALLORY DR
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-9279
Mailing Address - Country:US
Mailing Address - Phone:630-806-8347
Mailing Address - Fax:
Practice Address - Street 1:12700 SACRAMENTO AVE
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-1822
Practice Address - Country:US
Practice Address - Phone:708-597-6300
Practice Address - Fax:708-597-6386
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer