Provider Demographics
NPI:1326110313
Name:ERHARDT PHYSICAL THERAPY AND SPORTS MEDICINE, LLC
Entity Type:Organization
Organization Name:ERHARDT PHYSICAL THERAPY AND SPORTS MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP CHIEF COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:WADE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MEYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-296-2222
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:630-759-9510
Practice Address - Street 1:51385 SW OLD PORTLAND RD
Practice Address - Street 2:SUITE E
Practice Address - City:SCAPPOOSE
Practice Address - State:OR
Practice Address - Zip Code:97056-4061
Practice Address - Country:US
Practice Address - Phone:503-543-7768
Practice Address - Fax:503-543-7772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR029022Medicaid
ORDF4105OtherRAIL ROAD MEDICARE
OR029022Medicaid