Basic Information
| Provider Information | |||||||||
| NPI: | 1932231420 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BASIL | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.O.T. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | REIDELBACH | ||||||||
| OtherFirstName: | JILL | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.O.T. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9034 COLUMBIA AVE | ||||||||
| Address2: | |||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463212905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198360296 | ||||||||
| FaxNumber: | 2198360570 | ||||||||
| Practice Location | |||||||||
| Address1: | 9050 COLUMBIA AVE | ||||||||
| Address2: | |||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463212905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198360193 | ||||||||
| FaxNumber: | 2198360570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 31003833A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 000000484843 | 01 | IN | ANTHEM | OTHER |