Healthcare Provider Details

I. General information

NPI: 1154645422
Provider Name (Legal Business Name): DOUGLAS C BUELT P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2010
Last Update Date: 03/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 WABASH AVE
CARTHAGE IL
62321-1444
US

IV. Provider business mailing address

620 WABASH AVE
CARTHAGE IL
62321-1444
US

V. Phone/Fax

Practice location:
  • Phone: 217-357-9000
  • Fax: 217-357-9013
Mailing address:
  • Phone: 217-357-9000
  • Fax: 217-357-9013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070017691
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: