Provider Demographics
NPI:1205278827
Name:MARTIN, KEVIN J (PT DPT)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PT DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 W WACKER DR
Mailing Address - Street 2:SUITE 1020
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-1216
Mailing Address - Country:US
Mailing Address - Phone:312-640-0329
Mailing Address - Fax:
Practice Address - Street 1:150 E HURON ST
Practice Address - Street 2:SUITE 1205
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2999
Practice Address - Country:US
Practice Address - Phone:312-640-1112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-24
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070020092225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist