Provider Demographics
NPI:1457522542
Name:HOLZMAN, BENJAMIN J (MPT,LAT)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:J
Last Name:HOLZMAN
Suffix:
Gender:M
Credentials:MPT,LAT
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:630-759-3251
Practice Address - Street 1:15312 W BELOIT RD
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-7447
Practice Address - Country:US
Practice Address - Phone:262-641-5771
Practice Address - Fax:262-641-6317
Is Sole Proprietor?:No
Enumeration Date:2008-03-17
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10942-24225100000X
WI734-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1457522542Medicaid
WI830420019Medicare PIN
WI1457522542Medicaid
WI000680094Medicare PIN