MEDICARE: JUSTIN MATHEW KIESEL DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	05013406A	IN

General Provider Information

NPI Number	:	1548723810
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTIN MATHEW KIESEL DPT

Provider Business Mailing Address
First Line	:	600 OAKMONT LN STE 600C
Second Line	:
City	:	WESTMONT
State	:	IL
Zip	:	60559-5548
Country	:	US
Telephone Number	:	630-575-6200
Fax Number	:

Provider Business Practice Location Address
First Line	:	6280 N COLLEGE AVE STE 300
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-2029
Country	:	US
Telephone Number	:	317-251-0500
Fax Number	:	317-251-0600

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/12/2019
Last Update Date	:	05/04/2021

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