Provider Demographics
NPI:1649598020
Name:PHILLIPS, BRADLEY D (PT)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:D
Last Name:PHILLIPS
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 1:790 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:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:1275 N CONVENT ST
Practice Address - Street 2:SUITE 3
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-8210
Practice Address - Country:US
Practice Address - Phone:815-936-1855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-11
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00855692OtherMEDICARE RR
IL209812006Medicare PIN