Basic Information
| Provider Information | |||||||||
| NPI: | 1477595999 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLTZ SPANGLER | ||||||||
| FirstName: | EILEEN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KENNEDY | ||||||||
| OtherFirstName: | EILEEN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
| FaxNumber: | 6307593251 | ||||||||
| Practice Location | |||||||||
| Address1: | 213 GREENHILL AVE | ||||||||
| Address2: | STE C | ||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 198051844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026587800 | ||||||||
| FaxNumber: | 3026581550 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2006 | ||||||||
| LastUpdateDate: | 08/25/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | J10001871 | DE | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 5070-0025 | 01 | CARE FIRST | OTHER | 10000037584 | 05 | DE | MEDICAID | 1000037584 | 05 | DE | MEDICAID | 2398179000 | 01 | PA | AMERIHEALTH PROVIDER ID | OTHER | 1477595999 | 01 | CHAMPUS TRICARE | OTHER | 1730452 | 01 | PABS | OTHER | 2398179000 | 01 | AMERIHEALTH IBC | OTHER | 64249301 | 01 | NCA | OTHER |