Provider Demographics
NPI:1265634471
Name:MUSHINSKI, KEITH (PT)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:MUSHINSKI
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 1:790 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 1:2600 GLASGOW AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19702-4773
Practice Address - Country:US
Practice Address - Phone:302-838-2165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0002255225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
11797340OtherCAQH
DE1265634471Medicaid
2872480000OtherIBC AMERIHEALTH
1265634471OtherCHAMPUS TRICARE
2872480000OtherIBC AMERIHEALTH