Healthcare Provider Details

I. General information

NPI: 1679049514
Provider Name (Legal Business Name): JOHN MICHAEL DEIR PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2018
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10201 S CICERO AVE STE A
OAK LAWN IL
60453-4672
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-2549
US

V. Phone/Fax

Practice location:
  • Phone: 708-658-2770
  • Fax:
Mailing address:
  • Phone: 847-390-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.026917
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberBOC359051
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: