Provider Demographics
NPI:1013958784
Name:EDQUIBAN, MICHAEL L (PT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:L
Last Name:EDQUIBAN
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 1:5946 N MILWAUKEE AVENUE
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-5424
Mailing Address - Country:US
Mailing Address - Phone:773-775-6637
Mailing Address - Fax:773-775-6638
Practice Address - Street 1:5946 N MILWAUKEE AVENUE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-5424
Practice Address - Country:US
Practice Address - Phone:773-775-6637
Practice Address - Fax:773-775-6638
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070011407225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK13385Medicare PIN