Provider Demographics
NPI:1861446361
Name:PRICE, DEREK P (PT)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:P
Last Name:PRICE
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 1:303 N. WILLLIAM KUMPF BLVD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61605-2507
Mailing Address - Country:US
Mailing Address - Phone:309-676-5546
Mailing Address - Fax:
Practice Address - Street 1:303 N WILLIAM KUMPF BLVD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61605-2507
Practice Address - Country:US
Practice Address - Phone:309-676-5546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070009305225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCH8612OtherRR MEDICARE
ILQ47810Medicare UPIN
ILK19138Medicare ID - Type Unspecified