Provider Demographics
NPI:1952369472
Name:STORTZ, GEORGE LESLIE (PT)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:LESLIE
Last Name:STORTZ
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 1:1701 S FIRST AVE
Mailing Address - Street 2:STE 302
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153
Mailing Address - Country:US
Mailing Address - Phone:708-343-3566
Mailing Address - Fax:708-343-9235
Practice Address - Street 1:1701 S FIRST AVE
Practice Address - Street 2:STE 302
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153
Practice Address - Country:US
Practice Address - Phone:708-343-3566
Practice Address - Fax:708-343-9235
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK26090Medicare ID - Type Unspecified
ILK26616Medicare ID - Type Unspecified