Provider Demographics
NPI:1891121174
Name:IRVING, MICHAEL P (PT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:P
Last Name:IRVING
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4111 N ILLINOIS ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-7609
Mailing Address - Country:US
Mailing Address - Phone:618-235-0700
Mailing Address - Fax:618-235-0717
Practice Address - Street 1:610 E CITY ROUTE 40
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:IL
Practice Address - Zip Code:62246-2535
Practice Address - Country:US
Practice Address - Phone:618-664-9720
Practice Address - Fax:618-664-9721
Is Sole Proprietor?:No
Enumeration Date:2013-09-18
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.011590225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist