Provider Demographics
NPI:1336266915
Name:STORTZUM, GREGORY J (PT, MPT)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:J
Last Name:STORTZUM
Suffix:
Gender:M
Credentials:PT, MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-326-2911
Mailing Address - Fax:217-344-8047
Practice Address - Street 1:2403 VILLAGE GREEN PL
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-7676
Practice Address - Country:US
Practice Address - Phone:217-359-4549
Practice Address - Fax:217-344-8047
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4117OtherHAMP PROV ID
113326OtherHEALTHLINK PROV ID
7216OtherPERSONALCARE PROV ID
IL203OtherBLUE CROSS PROV ID
IL203OtherBLUE CROSS PROV ID