Provider Demographics
NPI:1497948053
Name:ZULTOWSKI, ILYSE F (PT)
Entity Type:Individual
Prefix:
First Name:ILYSE
Middle Name:F
Last Name:ZULTOWSKI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ILYSE
Other - Middle Name:F
Other - Last Name:BODDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2533 N SOUTHPORT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-7166
Mailing Address - Country:US
Mailing Address - Phone:773-472-2731
Mailing Address - Fax:
Practice Address - Street 1:2533 N SOUTHPORT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-7166
Practice Address - Country:US
Practice Address - Phone:773-472-2731
Practice Address - Fax:773-472-2761
Is Sole Proprietor?:No
Enumeration Date:2007-08-27
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL70015939225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1619908OtherBCBS IL GROUP
IL568150OtherMEDICARE GROUP NUMBER
ILK45773Medicare PIN