Provider Demographics
NPI:1790738409
Name:FUNCTIONAL PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:FUNCTIONAL PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:FRANCIS
Authorized Official - Last Name:FEDORSKI
Authorized Official - Suffix:
Authorized Official - Credentials:PT, ATC
Authorized Official - Phone:630-893-5534
Mailing Address - Street 1:152 S BLOOMINGDALE RD
Mailing Address - Street 2:UNIT 101
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-1481
Mailing Address - Country:US
Mailing Address - Phone:630-893-5534
Mailing Address - Fax:630-893-5527
Practice Address - Street 1:369 W ARMY TRAIL RD
Practice Address - Street 2:UNIT 14
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-2358
Practice Address - Country:US
Practice Address - Phone:630-893-5534
Practice Address - Fax:630-893-5527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-011136225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02232938OtherBLUE CROSS BLUE SHIELD
ILDH0131OtherRAILROAD MEDICARE
ILP00478856OtherRAILROAD MEDICARE
IL352586282001Medicaid
IL352586282001Medicaid