Provider Demographics
NPI:1720580467
Name:SYFERT, QUINLAN (PT)
Entity Type:Individual
Prefix:
First Name:QUINLAN
Middle Name:
Last Name:SYFERT
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 1:4147 N NEWCASTLE DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-1767
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2905 N MAIN ST STE G
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4276
Practice Address - Country:US
Practice Address - Phone:217-425-2600
Practice Address - Fax:217-425-2900
Is Sole Proprietor?:No
Enumeration Date:2018-03-07
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA090431225100000X
IL070.023544225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist