Provider Demographics
NPI:1831208693
Name:KILLIAN, MARK H (PT, LAT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:H
Last Name:KILLIAN
Suffix:
Gender:M
Credentials:PT, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1970 NAVAJO ST
Mailing Address - Street 2:
Mailing Address - City:RHINELANDER
Mailing Address - State:WI
Mailing Address - Zip Code:54501-8890
Mailing Address - Country:US
Mailing Address - Phone:715-420-1593
Mailing Address - Fax:715-362-0512
Practice Address - Street 1:1970 NAVAJO ST
Practice Address - Street 2:
Practice Address - City:RHINELANDER
Practice Address - State:WI
Practice Address - Zip Code:54501-8890
Practice Address - Country:US
Practice Address - Phone:715-420-1593
Practice Address - Fax:715-362-0512
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4902-024225100000X
WI38-0392255A2300X
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
WI40286100Medicaid
WI40286100Medicaid