MEDICARE: WYLDE PHYSICAL THERAPY, LLC

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	208100000X	Physical Medicine & Rehabilitation Physician
2	261QP2000X	Physical Therapy Clinic/Center
3	2251X0800X	Orthopedic Physical Therapist	070006362	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1932047	OTHER	IL	BCBS GROUP ID#

General Provider Information

NPI Number	:	1740406123
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WYLDE PHYSICAL THERAPY, LLC

Provider Business Mailing Address
First Line	:	PO BOX 98
Second Line	:
City	:	WATERMAN
State	:	IL
Zip	:	60556-0098
Country	:	US
Telephone Number	:	815-264-8600
Fax Number	:	331-431-5462

Provider Business Practice Location Address
First Line	:	320 W ADAMS ST
Second Line	:
City	:	WATERMAN
State	:	IL
Zip	:	60556-4000
Country	:	US
Telephone Number	:	815-264-8600
Fax Number	:	331-431-5462

Authorized Official
Title or Position	:	OWNER/PHYSICAL THERAPIST
Name	:	MICHELE WYLDE
Credential	:
Telephone Number	:	815-264-8600

Provider Enumeration Date	:	04/17/2007
Last Update Date	:	07/14/2025

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