Provider Demographics
NPI:1659525368
Name:PHOENIX PHYSICAL THERAPY
Entity Type:Organization
Organization Name:PHOENIX PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BUESCHER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:618-277-8577
Mailing Address - Street 1:4111 N ILLINOIS ST
Mailing Address - Street 2:STE C
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-7609
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4111 N ILLINOIS ST
Practice Address - Street 2:STE C
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-7609
Practice Address - Country:US
Practice Address - Phone:618-235-0700
Practice Address - Fax:618-235-0717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-07
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6262720001Medicare NSC