Basic Information
Provider Information | |||||||||
NPI: | 1932103348 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KUJAWA | ||||||||
FirstName: | MICHELLE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2810 FRANK SCOTT PKWY W | ||||||||
Address2: | SUITE 824 | ||||||||
City: | BELLEVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 622235007 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6182349705 | ||||||||
FaxNumber: | 6182570665 | ||||||||
Practice Location | |||||||||
Address1: | 211 E HANOVER ST | ||||||||
Address2: |   | ||||||||
City: | NEW BADEN | ||||||||
State: | IL | ||||||||
PostalCode: | 622651811 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6185884000 | ||||||||
FaxNumber: | 6185884800 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/13/2005 | ||||||||
LastUpdateDate: | 11/06/2009 | ||||||||
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 | 225100000X | 11-03291 | KS | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 2251X0800X |   |   | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 225100000X | 070.015449 | IL | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | P00751927 | 01 | IL | MEDICARE RAILROAD GRP PTAN | OTHER |