Healthcare Provider Details

I. General information

NPI: 1972939593
Provider Name (Legal Business Name): ELIZABETH BLUDGEN MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2013
Last Update Date: 05/25/2023
Certification Date: 05/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12004 S ROUTE 59 UNIT 100
PLAINFIELD IL
60585-5108
US

IV. Provider business mailing address

PO BOX 713260
CHICAGO IL
60677-0018
US

V. Phone/Fax

Practice location:
  • Phone: 815-416-6652
  • Fax:
Mailing address:
  • Phone: 630-469-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070008012
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: