Provider Demographics
NPI:1851333694
Name:ANGELETTI, GINA PONGETTI (MPT)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:PONGETTI
Last Name:ANGELETTI
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:MARIE
Other - Last Name:PONGETTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:100 E WALTON ST
Mailing Address - Street 2:SUITE 700
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-1448
Mailing Address - Country:US
Mailing Address - Phone:312-642-3963
Mailing Address - Fax:312-642-3966
Practice Address - Street 1:7055 HIGH GROVE BLVD
Practice Address - Street 2:
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-7593
Practice Address - Country:US
Practice Address - Phone:630-371-1623
Practice Address - Fax:630-371-1546
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070013170225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1623066OtherBCBS PROVIDER NUMBER
IL204585012Medicare PIN
ILK51855Medicare PIN
ILK51854Medicare PIN
ILK21226Medicare PIN
IL1623066OtherBCBS PROVIDER NUMBER
ILK51853Medicare PIN