Healthcare Provider Details

I. General information

NPI: 1992219638
Provider Name (Legal Business Name): DANIEL C ROUTH PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2017
Last Update Date: 03/21/2022
Certification Date: 03/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 S SWEETBRIAR DR STE C
CHILLICOTHEE IL
61523-2266
US

IV. Provider business mailing address

2900 FRANK SCOTT PKWY W STE 928
BELLEVILLE IL
62223-5000
US

V. Phone/Fax

Practice location:
  • Phone: 309-274-6314
  • Fax: 309-274-4100
Mailing address:
  • Phone: 618-234-9705
  • Fax: 618-234-9867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: