Healthcare Provider Details

I. General information

NPI: 1598289142
Provider Name (Legal Business Name): KEITH FRANKLIN BUMGARDNER JR. DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2017
Last Update Date: 02/27/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

849 S ROUTE 51 STE D
FORSYTH IL
62535-8808
US

IV. Provider business mailing address

849 S ROUTE 51 STE D
FORSYTH IL
62535-8808
US

V. Phone/Fax

Practice location:
  • Phone: 217-872-2244
  • Fax:
Mailing address:
  • Phone: 217-872-2244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number007133
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.024270
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: