Provider Demographics
NPI:1619981081
Name:WORTHINGTON, WILLIAM O (PT)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:O
Last Name:WORTHINGTON
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:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:IL
Mailing Address - Zip Code:62441
Mailing Address - Country:US
Mailing Address - Phone:217-826-2365
Mailing Address - Fax:217-826-8120
Practice Address - Street 1:410 N SECOND STREET
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:IL
Practice Address - Zip Code:62441
Practice Address - Country:US
Practice Address - Phone:217-826-2365
Practice Address - Fax:217-826-8120
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070010429225100000X
IN05005753A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00397106OtherRAILROAD UPIN
IL1232012OtherBLUE CROSS KINETIC 2010
IL080647OtherHEALTH ALLIANCE
IL010934666OtherKINETIC TAX ID
ILIL2959002Medicare UPIN
IL010934666OtherKINETIC TAX ID