Provider Demographics
NPI:1730467135
Name:MED PLUS PHYSICAL MEDICINE LLC
Entity Type:Organization
Organization Name:MED PLUS PHYSICAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:W
Authorized Official - Last Name:BRETZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-594-3671
Mailing Address - Street 1:18209 EULA MAE PKWY
Mailing Address - Street 2:
Mailing Address - City:CARLYLE
Mailing Address - State:IL
Mailing Address - Zip Code:62231-6407
Mailing Address - Country:US
Mailing Address - Phone:618-594-3671
Mailing Address - Fax:618-594-8058
Practice Address - Street 1:20 PROFESSIONAL PARK DR
Practice Address - Street 2:SUITE A
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5830
Practice Address - Country:US
Practice Address - Phone:618-288-5044
Practice Address - Fax:618-288-9472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-02
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL248000193208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL4910Medicare UPIN