Provider Demographics
NPI:1457307498
Name:WELDER, BRYAN PAUL (MPT)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:PAUL
Last Name:WELDER
Suffix:
Gender:M
Credentials:MPT
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:630-296-2222
Mailing Address - Fax:
Practice Address - Street 1:27 S WESTERN AVE STE B
Practice Address - Street 2:
Practice Address - City:CARPENTERSVILLE
Practice Address - State:IL
Practice Address - Zip Code:60110-1715
Practice Address - Country:US
Practice Address - Phone:630-296-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6519024225100000X
IL070011738225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL33874990001Medicaid
ILIL6238010OtherMEDICARE
WI00485940OtherMEDICARE WI
ILIL6237010OtherMEDICARE
ILIL6697011OtherMEDICARE
WI40462600OtherMEDICAID WI
WI40462600OtherMEDICAID WI
ILIL6238010OtherMEDICARE