Provider Demographics
NPI:1649509324
Name:MILTON, ELLEN DEGEN (PT)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:DEGEN
Last Name:MILTON
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 1:219 E VANDALIA ST
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-1766
Mailing Address - Country:US
Mailing Address - Phone:618-624-9300
Mailing Address - Fax:
Practice Address - Street 1:219 E VANDALIA ST
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-1766
Practice Address - Country:US
Practice Address - Phone:618-659-9666
Practice Address - Fax:618-659-9668
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-09
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070014954225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL532400006Medicare PIN