Provider Demographics
NPI:1689681520
Name:WIEBUSCH PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:WIEBUSCH PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACI
Authorized Official - Middle Name:WIEBUSCH
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:773-750-7648
Mailing Address - Street 1:1701 WEST WRIGHTWOOD AVENUE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-7335
Mailing Address - Country:US
Mailing Address - Phone:773-750-7648
Mailing Address - Fax:773-327-7470
Practice Address - Street 1:900 N NORTH BRANCH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-4278
Practice Address - Country:US
Practice Address - Phone:773-750-7648
Practice Address - Fax:773-327-7470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01634891OtherBLUE CROSS BLUE SHIELD
IL210787Medicare ID - Type Unspecified