Provider Demographics
NPI:1023103132
Name:ANDRES, JEFFREY THOMAS (PT)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:THOMAS
Last Name:ANDRES
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 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:5849 W SAGINAW HWY
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-2460
Practice Address - Country:US
Practice Address - Phone:517-827-8644
Practice Address - Fax:517-323-4935
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011982225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI30647OtherBCBS
MI30647OtherBCBS
MI236573Medicare ID - Type UnspecifiedMEDICARE