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NPI Code Detail

MEDICARE: THERESA ANN KNOLL MPT

MEDICARE: THERESA ANN KNOLL MPT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225100000XPhysical Therapist8149TN
2225100000XPhysical Therapist070017118IL
3225100000XPhysical TherapistPT60736405WA

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1769380OTHERILMEDICARE GROUP PTAN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
210115176OTHERILBCBS GRP #

General Provider Information

NPI Number : 1124264478
Entity Type Code : Individual
Provider Name (Legal Business Name) : THERESA ANN KNOLL MPT
Provider Business Mailing Address
First Line : 210 SE PIONEER WAY
Second Line : STE 2
City : OAK HARBOR
State : WA
Zip : 98277-5705
Country : US
Telephone Number : 360-679-8600
Fax Number :
Provider Business Practice Location Address
First Line : 3475 S ALPINE RD
Second Line : PHYSICIANS IMMEDIATE CARE
City : ROCKFORD
State : IL
Zip : 61109-2604
Country : US
Telephone Number : 815-874-8000
Fax Number : 815-874-7525
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/16/2008
Last Update Date : 10/09/2017

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Directions to “ THERESA ANN KNOLL MPT” Practice Location

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