Provider Demographics
NPI:1932327863
Name:GULOTTA, BENJAMIN J (PT)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:J
Last Name:GULOTTA
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 1:3401 N. PERRYVILLE RD
Mailing Address - Street 2:ROCKFORD HEALTH PHYSICIANS
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114
Mailing Address - Country:US
Mailing Address - Phone:815-971-2000
Mailing Address - Fax:
Practice Address - Street 1:3401 N. PERRYVILLE RD.
Practice Address - Street 2:ROCKFORD HEALTH PHYSICIANS
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114
Practice Address - Country:US
Practice Address - Phone:815-971-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070008382225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P78641Medicare UPIN
ILK27355Medicare ID - Type Unspecified