Provider Demographics
NPI:1467658286
Name:WESOLOWSKI, DEREK (MSPT)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:WESOLOWSKI
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 KANEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-2578
Mailing Address - Country:US
Mailing Address - Phone:630-584-1411
Mailing Address - Fax:630-513-2630
Practice Address - Street 1:1975 LIN LOR LN
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-4902
Practice Address - Country:US
Practice Address - Phone:847-468-6098
Practice Address - Fax:847-468-6095
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CF2064OtherRAILROAD GROUP
753210OtherMEDICARE GROUP
ILK39995OtherMEDICARE