Provider Demographics
NPI:1629551312
Name:SHULTZ, TANNER
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:
Last Name:SHULTZ
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 1:27W157 WALNUT DR
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-2051
Mailing Address - Country:US
Mailing Address - Phone:630-390-8417
Mailing Address - Fax:
Practice Address - Street 1:27W157 WALNUT DR
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-2051
Practice Address - Country:US
Practice Address - Phone:630-390-8417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL224Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Y00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersClinical Exercise Physiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL26-1393224Medicaid