Provider Demographics
NPI:1346350568
Name:MARTIN, MARY ELLEN (PT)
Entity Type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 W WACKER DR
Mailing Address - Street 2:SUITE 1020
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-1216
Mailing Address - Country:US
Mailing Address - Phone:312-640-0329
Mailing Address - Fax:
Practice Address - Street 1:2900 FOXFIELD RD
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-5799
Practice Address - Country:US
Practice Address - Phone:630-587-5788
Practice Address - Fax:630-587-8570
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070004444225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL367885100OtherUS DEPT OF LABOR
IL1623066OtherBCBS OF ILLINOIS
IL1619908OtherBCBS OF IL GROUP NUMBER
IL367885100OtherUS DEPT OF LABOR
IL200852Medicare ID - Type UnspecifiedMEDICARE GROUP #
IL568080Medicare PIN
ILK52170Medicare PIN
IL568150Medicare PIN
IL567700Medicare PIN
IL1623066OtherBCBS OF ILLINOIS
ILK52169Medicare PIN