Provider Demographics
NPI:1932103348
Name:KUJAWA, MICHELLE (PT)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:KUJAWA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 FRANK SCOTT PKWY W
Mailing Address - Street 2:SUITE 824
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-5007
Mailing Address - Country:US
Mailing Address - Phone:618-234-9705
Mailing Address - Fax:618-257-0665
Practice Address - Street 1:211 E HANOVER ST
Practice Address - Street 2:
Practice Address - City:NEW BADEN
Practice Address - State:IL
Practice Address - Zip Code:62265-1811
Practice Address - Country:US
Practice Address - Phone:618-588-4000
Practice Address - Fax:618-588-4800
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-03291225100000X
2251X0800X
IL070.015449225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00751927OtherMEDICARE RAILROAD GRP PTAN
ILP00751927OtherMEDICARE RAILROAD GRP PTAN