Basic Information
| Provider Information | |||||||||
| NPI: | 1457522542 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLZMAN | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MPT,LAT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
| FaxNumber: | 6307593251 | ||||||||
| Practice Location | |||||||||
| Address1: | 15312 W BELOIT RD | ||||||||
| Address2: | |||||||||
| City: | NEW BERLIN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531517447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626415771 | ||||||||
| FaxNumber: | 2626416317 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2008 | ||||||||
| LastUpdateDate: | 07/24/2014 | ||||||||
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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 | 10942-24 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2255A2300X | 734-39 | WI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
ID Information
| ID | Type | State | Issuer | Description | 1457522542 | 05 | WI | MEDICAID |