Provider Demographics
NPI:1407080153
Name:HERLIHY, MICHAEL J (PT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:HERLIHY
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:866-370-8206
Mailing Address - Fax:
Practice Address - Street 1:2835 N GRANDVIEW BLVD STE 100
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-5546
Practice Address - Country:US
Practice Address - Phone:262-574-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-11
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05010782A225100000X
WI12772-24225100000X
IL070017165225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100288649Medicaid
WI100039803Medicaid
ILP00931570OtherMEDICARE RAILROAD
IL205782011Medicare PIN
IL212608004Medicare PIN
IL211082007Medicare PIN
IL216859073Medicare PIN
ILP00931570OtherMEDICARE RAILROAD