=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043658743
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDWARD J HODEL IV PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2013
-----------------------------------------------------
Last Update Date | 12/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 N MAIN ST
-----------------------------------------------------
City | EUREKA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61530-1085
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-467-2337
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2988 COURT ST
-----------------------------------------------------
City | PEKIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61554-6229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-353-5940
-----------------------------------------------------
Fax | 309-353-1654
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 070020015
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------