Provider Demographics
NPI:1881720381
Name:CASTILLO, CARLO CORTEZ (PT)
Entity type:Individual
Prefix:
First Name:CARLO
Middle Name:CORTEZ
Last Name:CASTILLO
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 1:790 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:
Mailing Address - Fax:
Practice Address - Street 1:1975 LIN LOR LN
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-4902
Practice Address - Country:US
Practice Address - Phone:847-468-6098
Practice Address - Fax:847-468-6095
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501013141225100000X
IL070-013676225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00931566OtherMEDICARE RAILROAD
MIP09920011OtherMEDICARE ID UNSPECIFIED
ILP00931566OtherMEDICARE RAILROAD
MIP09920011OtherMEDICARE ID UNSPECIFIED
MI0P09920Medicare PIN
IL205782006Medicare PIN