Basic Information
| Provider Information | |||||||||
| NPI: | 1609152735 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ATHEY | ||||||||
| FirstName: | BROCK | ||||||||
| MiddleName: | WAYNE | ||||||||
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| Credential: | MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1303 W EVERGREEN AVE | ||||||||
| Address2: | BIOMAX STE 102 | ||||||||
| City: | EFFINGHAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173433400 | ||||||||
| FaxNumber: | 2173429714 | ||||||||
| Practice Location | |||||||||
| Address1: | 1303 W EVERGREEN AVE | ||||||||
| Address2: | BIOMAX STE 102 | ||||||||
| City: | EFFINGHAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173433400 | ||||||||
| FaxNumber: | 2173429714 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2011 | ||||||||
| LastUpdateDate: | 11/03/2011 | ||||||||
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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 | 070018141 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.