Provider Demographics
NPI:1265629307
Name:SWIDERGAL, KRISTIN M (PT)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:M
Last Name:SWIDERGAL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:M
Other - Last Name:PYCZ
Other - Suffix:II
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:806 LARAWAY RD
Practice Address - Street 2:808
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-2694
Practice Address - Country:US
Practice Address - Phone:815-462-8416
Practice Address - Fax:815-462-8425
Is Sole Proprietor?:No
Enumeration Date:2007-10-03
Last Update Date:2011-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070011465225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00931608OtherMEDICARE RAILROAD
ILK45585Medicare PIN
ILP00471780Medicare PIN
IL209812014Medicare PIN
ILP00931608OtherMEDICARE RAILROAD