Provider Demographics
NPI:1891819454
Name:INGRISANO, ROBERT G
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:G
Last Name:INGRISANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9132 OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60513-1943
Mailing Address - Country:US
Mailing Address - Phone:708-562-0999
Mailing Address - Fax:708-562-1934
Practice Address - Street 1:9132 OGDEN AVE APT 1
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:IL
Practice Address - Zip Code:60513-2941
Practice Address - Country:US
Practice Address - Phone:708-562-0999
Practice Address - Fax:708-562-1934
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070002424225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1617848OtherBLUE CROSS
IL131415300OtherUS DEPARTMENT OF LABOR
IL1617848OtherBLUE CROSS