Provider Demographics
NPI:1801909627
Name:KORDUCKI, MARK J (MPT)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:J
Last Name:KORDUCKI
Suffix:
Gender:M
Credentials:MPT
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:414-761-0727
Mailing Address - Fax:
Practice Address - Street 1:3111 W RAWSON AVE
Practice Address - Street 2:SUITE 215
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-9417
Practice Address - Country:US
Practice Address - Phone:414-761-0727
Practice Address - Fax:414-761-0785
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5407024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40302200Medicaid
P22045Medicare UPIN