Provider Demographics
NPI:1831275379
Name:GENTRY, GEOFFREY J (PT)
Entity type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:J
Last Name:GENTRY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12172 S STATE ROUTE 47 STE 319
Mailing Address - Street 2:
Mailing Address - City:HUNTLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60142-9619
Mailing Address - Country:US
Mailing Address - Phone:312-804-9332
Mailing Address - Fax:815-943-0196
Practice Address - Street 1:109 W FRONT ST
Practice Address - Street 2:
Practice Address - City:HARVARD
Practice Address - State:IL
Practice Address - Zip Code:60033-2833
Practice Address - Country:US
Practice Address - Phone:312-804-9332
Practice Address - Fax:815-943-0196
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL070.010571225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK14168Medicare ID - Type Unspecified