Basic Information
| Provider Information | |||||||||
| NPI: | 1306938972 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENTWHISTLE | ||||||||
| FirstName: | ALYSON | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JIRMASEK | ||||||||
| OtherFirstName: | ALYSON | ||||||||
| OtherMiddleName: | R | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 80 TEMPLETON DR | ||||||||
| Address2: | |||||||||
| City: | OSWEGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605437000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305543456 | ||||||||
| FaxNumber: | 6305512970 | ||||||||
| Practice Location | |||||||||
| Address1: | 80 TEMPLETON DR | ||||||||
| Address2: | |||||||||
| City: | OSWEGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305543456 | ||||||||
| FaxNumber: | 6305512970 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 12/07/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070013107 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P00882382 | 01 | IL | MEDICARE RAILROAD | OTHER | P00931542 | 01 | IL | MEDICARE RAILROAD | OTHER |