Healthcare Provider Details

I. General information

NPI: 1457307498
Provider Name (Legal Business Name): BRYAN PAUL WELDER MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 03/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 S WESTERN AVE STE B
CARPENTERSVILLE IL
60110-1715
US

IV. Provider business mailing address

790 REMINGTON BLVD
BOLINGBROOK IL
60440-4909
US

V. Phone/Fax

Practice location:
  • Phone: 630-296-2222
  • Fax:
Mailing address:
  • Phone: 630-296-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number6519024
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070011738
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: