Provider Demographics
NPI:1912907254
Name:STEWART, JIM (PT)
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:
Last Name:STEWART
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 1:3003 W GOOD HOPE RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-2042
Mailing Address - Country:US
Mailing Address - Phone:414-352-3100
Mailing Address - Fax:
Practice Address - Street 1:215 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WI
Practice Address - Zip Code:53024-1700
Practice Address - Country:US
Practice Address - Phone:262-375-3700
Practice Address - Fax:262-375-6306
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9653-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40445700Medicaid
WIP00452811OtherRR MEDICARE
WI40445700Medicaid
WI46236-0126Medicare PIN
WIP00452811OtherRR MEDICARE