Healthcare Provider Details

I. General information

NPI: 1588780175
Provider Name (Legal Business Name): MICHAEL J MAEDER OTR L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1504 EAST GROVE
RANTOUL IL
61866-2736
US

IV. Provider business mailing address

611 W PARK ST
URBANA IL
61801-2500
US

V. Phone/Fax

Practice location:
  • Phone: 217-893-7720
  • Fax: 217-893-7803
Mailing address:
  • Phone: 217-326-2911
  • Fax: 217-344-8047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: