Healthcare Provider Details

I. General information

NPI: 1346859477
Provider Name (Legal Business Name): MODERN ATHLETE PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2020
Last Update Date: 07/24/2020
Certification Date: 07/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1033 PROGRESS DR
GRAYSLAKE IL
60030-1672
US

IV. Provider business mailing address

32 LYNN DR
HAWTHORN WOODS IL
60047-9102
US

V. Phone/Fax

Practice location:
  • Phone: 847-257-5172
  • Fax:
Mailing address:
  • Phone: 847-257-5172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL TODD BITZER
Title or Position: OWNER, PHYSICAL THERAPIST
Credential: PT
Phone: 847-257-5172