Basic Information
| Provider Information | |||||||||
| NPI: | 1992977185 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IMMEKUS | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | GABRIEL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1808 W BELTLINE HWY | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537132334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082501497 | ||||||||
| FaxNumber: | 6082501384 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 TOWER DR | ||||||||
| Address2: | |||||||||
| City: | SUN PRAIRIE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535901239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088253500 | ||||||||
| FaxNumber: | 6088253598 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2008 | ||||||||
| LastUpdateDate: | 03/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 10962-024 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.