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General NPI Number Information
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NPI Number | 1346859477
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Entity Type | Organization
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Legal Business Name | MODERN ATHLETE PHYSICAL THERAPY LLC
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Dates
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Enumeration Date | 07/24/2020
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Last Update Date | 07/24/2020
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Provider Practice Location Address
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Address Line | 1033 PROGRESS DR
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City | GRAYSLAKE
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State | IL
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Zip | 60030-1672
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Country | US
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Telephone | 847-257-5172
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Fax |
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Provider Business Mailing Address
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Address Line | 32 LYNN DR
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City | HAWTHORN WOODS
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State | IL
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Zip | 60047-9102
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Country | US
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Telephone | 847-257-5172
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Fax |
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Authorized Official
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Title or Position | OWNER, PHYSICAL THERAPIST
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Name | MICHAEL TODD BITZER
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Credential | PT
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Telephone | 847-257-5172
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2251S0007X
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Taxonomy Name | Sports Physical Therapist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 2251X0800X
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Taxonomy Name | Orthopedic Physical Therapist
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License Number |
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License Number State |
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