Basic Information
| Provider Information | |||||||||
| NPI: | 1265873756 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FISHER | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 N 27TH ST | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622266621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182356600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 150 N 27TH ST | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622266621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182356600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2013 | ||||||||
| LastUpdateDate: | 07/11/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070018228 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 2011009210 | MO | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.