Healthcare Provider Details

I. General information

NPI: 1114213196
Provider Name (Legal Business Name): ERIC BELLM DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2011
Last Update Date: 01/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

852 GREEN BAY RD
WINNETKA IL
60093-1853
US

IV. Provider business mailing address

852 GREEN BAY RD
WINNETKA IL
60093-1853
US

V. Phone/Fax

Practice location:
  • Phone: 847-441-5788
  • Fax: 847-784-8720
Mailing address:
  • Phone: 847-441-5788
  • Fax: 847-784-8720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070-019688
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number2011019590
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: