Provider Demographics
NPI:1518923754
Name:SVOBODA, KEVIN ALAN (PT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:ALAN
Last Name:SVOBODA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8813
Mailing Address - Country:US
Mailing Address - Phone:630-575-1980
Mailing Address - Fax:
Practice Address - Street 1:1333 COLLEGE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:SOUTH MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53172-1150
Practice Address - Country:US
Practice Address - Phone:414-571-9146
Practice Address - Fax:414-571-9147
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012949225100000X
WI6069-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP01161193OtherRAILROAD MEDICARE
WIWI2660002OtherMEDICARE
WI1518923754Medicaid
WI859400081OtherMEDICARE
WI859400081OtherMEDICARE
ILK49056Medicare PIN
WIP01161193OtherRAILROAD MEDICARE
ILK23619Medicare ID - Type Unspecified
WIWI2660002OtherMEDICARE
ILP00119785Medicare UPIN
WI1518923754Medicaid
ILP00119785Medicare PIN
WI801360002Medicare PIN