Provider Demographics
NPI:1598815128
Name:LARUE, BRIAN (DPT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:LARUE
Suffix:
Gender:M
Credentials:DPT
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:
Mailing Address - Fax:
Practice Address - Street 1:100 VALLEY CENTER RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19808-2950
Practice Address - Country:US
Practice Address - Phone:302-994-1200
Practice Address - Fax:302-994-1233
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ10002000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
88760507OtherCAREFIRST
DEJ10002000OtherDE LICENSE
PA10000040229OtherAMERIHEALTH/IBC
PA105165OtherPA BCBS
5070-0053OtherCAREFIRST
DE1000038248Medicaid
PA105165OtherPA BCBS
DEJ10002000OtherDE LICENSE
P00431161Medicare PIN