Healthcare Provider Details

I. General information

NPI: 1285875864
Provider Name (Legal Business Name): STEPHANIE KASKAVAGE PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2009
Last Update Date: 03/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 FAIRWAY DR
FREEPORT IL
61032-6600
US

IV. Provider business mailing address

421 W EXCHANGE ST PO BOX 268
FREEPORT IL
61032-4008
US

V. Phone/Fax

Practice location:
  • Phone: 815-599-6000
  • Fax:
Mailing address:
  • Phone: 815-599-7958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number070016902
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: