Provider Demographics
NPI:1346225786
Name:MENDICINO, STEPHEN M (PT)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:M
Last Name:MENDICINO
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 1:625 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8813
Mailing Address - Country:US
Mailing Address - Phone:630-575-6200
Mailing Address - Fax:630-928-5080
Practice Address - Street 1:1951 NEWARK GRANVILLE RD
Practice Address - Street 2:
Practice Address - City:GRANVILLE
Practice Address - State:OH
Practice Address - Zip Code:43023-9170
Practice Address - Country:US
Practice Address - Phone:740-321-1021
Practice Address - Fax:740-321-1022
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT-04782225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHME4163991Medicare ID - Type Unspecified