Provider Demographics
NPI:1699033068
Name:DOUGHERTY, CHRISTOPHER MICHAEL (PT)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:MICHAEL
Last Name:DOUGHERTY
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 1:1600 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19802-4722
Practice Address - Country:US
Practice Address - Phone:302-656-2521
Practice Address - Fax:302-656-2620
Is Sole Proprietor?:No
Enumeration Date:2012-04-24
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0003011225100000X
PAPT022116225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA245161VKFMedicare PIN