Basic Information
| Provider Information | |||||||||
| NPI: | 1104928910 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SLINDE | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 78534 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532788534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153989491 | ||||||||
| FaxNumber: | 8153817498 | ||||||||
| Practice Location | |||||||||
| Address1: | 324 ROXBURY RD | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611075090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153989491 | ||||||||
| FaxNumber: | 8153817498 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2006 | ||||||||
| LastUpdateDate: | 12/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070011604 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1619908 | 01 | IL | BCBS IL GROUP NUMBER | OTHER | CJ8115 | 01 | IL | R.R. MEDICARE GROUP # | OTHER | 1623066 | 01 | IL | BCBS PROVIDER # | OTHER | 367885100 | 01 | IL | US DEPT OF LABOR # | OTHER | 650022980 | 01 | IL | R.R. MEDICARE PIN | OTHER |