Provider Demographics
NPI:1346859477
Name:MODERN ATHLETE PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:MODERN ATHLETE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:BITZER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:847-257-5172
Mailing Address - Street 1:32 LYNN DR
Mailing Address - Street 2:
Mailing Address - City:HAWTHORN WOODS
Mailing Address - State:IL
Mailing Address - Zip Code:60047-9102
Mailing Address - Country:US
Mailing Address - Phone:847-257-5172
Mailing Address - Fax:
Practice Address - Street 1:1033 PROGRESS DR
Practice Address - Street 2:
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-1672
Practice Address - Country:US
Practice Address - Phone:847-257-5172
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-24
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty