Provider Demographics
NPI:1609546084
Name:LYSIK, MATTHEW R
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:R
Last Name:LYSIK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 S MICHIGAN AVE UNIT 105
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-1636
Mailing Address - Country:US
Mailing Address - Phone:815-603-8833
Mailing Address - Fax:
Practice Address - Street 1:1801 S MICHIGAN AVE UNIT 105
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-1636
Practice Address - Country:US
Practice Address - Phone:815-603-8833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.009235225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant