1902233075 NPI number — MR. MANESH MATHEW ILLIMOOTTIL PHYSICAL THERAPIST

Table of content: MR. MANESH MATHEW ILLIMOOTTIL PHYSICAL THERAPIST (NPI 1902233075)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902233075 NPI number — MR. MANESH MATHEW ILLIMOOTTIL PHYSICAL THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ILLIMOOTTIL
Provider First Name:
MANESH
Provider Middle Name:
MATHEW
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PHYSICAL THERAPIST
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902233075
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3703 W LAKE AVE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
GLENVIEW
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60026-1223
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-998-1188
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3703 W LAKE AVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
GLENVIEW
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60026-1223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-998-1188
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/03/2013

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: 225100000X , with the licence number:  070.011946 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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