Provider Demographics
NPI:1639735418
Name:PANOPTIC PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:PANOPTIC PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:MERTES
Authorized Official - Suffix:III
Authorized Official - Credentials:LNHA
Authorized Official - Phone:815-513-3298
Mailing Address - Street 1:1802 DIVISION ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450
Mailing Address - Country:US
Mailing Address - Phone:815-513-3298
Mailing Address - Fax:815-513-5446
Practice Address - Street 1:1521 N CONVENT ST
Practice Address - Street 2:SUITE 1000
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914
Practice Address - Country:US
Practice Address - Phone:815-210-9010
Practice Address - Fax:815-513-5446
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PANOPTIC PHYSICAL THERAPY LL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-05-16
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty