Provider Demographics
NPI:1548212566
Name:ERHARDT, JONATHAN WADE (PT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:WADE
Last Name:ERHARDT
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 1:790 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:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:51385 SW OLD PORTLAND RD
Practice Address - Street 2:
Practice Address - City:SCAPPOOSE
Practice Address - State:OR
Practice Address - Zip Code:97056-4061
Practice Address - Country:US
Practice Address - Phone:503-543-7768
Practice Address - Fax:503-543-7772
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3420225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORDF4105OtherRAILROAD MEDICARE
OR029036Medicaid
ORDF4105OtherRAILROAD MEDICARE
OR119365Medicare PIN