Provider Demographics
NPI:1942812276
Name:TISCH, JOHN HUNTER (DPT, PT)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:HUNTER
Last Name:TISCH
Suffix:
Gender:M
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11907 N HICKORY GROVE RD
Mailing Address - Street 2:
Mailing Address - City:DUNLAP
Mailing Address - State:IL
Mailing Address - Zip Code:61525-9259
Mailing Address - Country:US
Mailing Address - Phone:309-645-7424
Mailing Address - Fax:
Practice Address - Street 1:2359 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-3902
Practice Address - Country:US
Practice Address - Phone:309-353-4767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070025325225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist