Provider Demographics
NPI:1174657050
Name:HILLESHEIM, MARK T (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:HILLESHEIM
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 1:5476 MICHAELS DR
Mailing Address - Street 2:#6
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-8663
Mailing Address - Country:US
Mailing Address - Phone:920-730-4030
Mailing Address - Fax:
Practice Address - Street 1:3130 SHORE DR
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-4291
Practice Address - Country:US
Practice Address - Phone:715-735-4609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3372225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40137800Medicaid