1609128453 NPI number — MYRA J KURTZ PHYSICAL THERAPIST

Table of content: MYRA J KURTZ PHYSICAL THERAPIST (NPI 1609128453)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609128453 NPI number — MYRA J KURTZ PHYSICAL THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KURTZ
Provider First Name:
MYRA
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHYSICAL THERAPIST
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GUDEMAN
Provider Other First Name:
MYRA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1609128453
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/30/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
790 REMINGTON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOLINGBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60440-4909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-296-2222
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3315 S 23RD ST
Provider Second Line Business Practice Location Address:
STE 210
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98405-1605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-572-8684
Provider Business Practice Location Address Fax Number:
253-284-0450
Provider Enumeration Date:
10/03/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171W00000X , with the licence number:  PT00009756 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT00009756 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PT00009756 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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