Provider Demographics
NPI:1184889727
Name:CRONIN, KELLY (PT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CRONIN
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 1:790 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 1:23915 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60544-1967
Practice Address - Country:US
Practice Address - Phone:815-609-0570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-011015225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00943108OtherMEDICARE RAILROAD
ILP00943108OtherMEDICARE RAILROAD
IL212608006Medicare PIN
IL202845180Medicare PIN
IL211082010Medicare PIN
IL205782013Medicare PIN
IL202845043Medicare PIN