Provider Demographics
NPI:1710077557
Name:WAX, KATHERINE (PT)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:WAX
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 W OAKDALE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657
Mailing Address - Country:US
Mailing Address - Phone:815-834-2400
Mailing Address - Fax:815-834-2424
Practice Address - Street 1:7225 W COLLEGE DR
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1101
Practice Address - Country:US
Practice Address - Phone:708-361-5355
Practice Address - Fax:708-361-5399
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-014502225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00238078OtherR.R. MEDICARE PIN #
ILCJ4383OtherR.R. MEDICARE GRP#
IL1623066OtherBCBS PROVIDER #
IL367885100OtherUS DEPT OF LABOR PROV #
ILP00238078OtherR.R. MEDICARE PIN #
ILK19480Medicare PIN
IL202542Medicare ID - Type UnspecifiedMEDICARE GROUP #
IL200852Medicare ID - Type UnspecifiedMEDICARE GROUP #