Provider Demographics
NPI:1760433106
Name:DORMAN, JERZY (PT)
Entity Type:Individual
Prefix:
First Name:JERZY
Middle Name:
Last Name:DORMAN
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 1:707 LAKE COOK RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-5613
Mailing Address - Country:US
Mailing Address - Phone:847-509-0600
Mailing Address - Fax:847-580-1215
Practice Address - Street 1:707 LAKE COOK RD
Practice Address - Street 2:SUITE 120
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-5613
Practice Address - Country:US
Practice Address - Phone:847-509-0600
Practice Address - Fax:847-580-1215
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070009910225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
3606513OtherAETNA
5543133OtherCCN
693206OtherACN
K10728Medicare UPIN
01634605OtherBCBS
2237812OtherFIRST HEALTH
200736705OtherHUMANA
200736705OtherPHCS
7260716OtherCIGNA
210012Medicare ID - Type Unspecified