Basic Information
| Provider Information | |||||||||
| NPI: | 1659659209 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAAR | ||||||||
| FirstName: | JAIME | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LORUSSO | ||||||||
| OtherFirstName: | JAIME | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 15 APEX DR | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | HIGHLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622491282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184410482 | ||||||||
| FaxNumber: | 6184410482 | ||||||||
| Practice Location | |||||||||
| Address1: | 5701 GODFREY RD | ||||||||
| Address2: | |||||||||
| City: | GODFREY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620352471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184339919 | ||||||||
| FaxNumber: | 6184331455 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2011 | ||||||||
| LastUpdateDate: | 06/07/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | 070.018551 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
ID Information
| ID | Type | State | Issuer | Description | 900068033 | 01 | IL | UNITED HEALTHCARE | OTHER | P01003127 | 01 | IL | RR MEDICARE | OTHER | 146703 | 01 | IL | MEDICARE PART A | OTHER | 900068033 | 01 | IL | HEALTHLINK | OTHER | 900068033 | 01 | IL | HNFS TRICARE | OTHER | 900068033 | 01 | IL | AETNA | OTHER | 900068033 | 01 | IL | BCBS OF ILLINOIS | OTHER |