Basic Information
Provider Information
NPI: 1003017187
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GURLEY
FirstName: ROGER
MiddleName: KEITH
NamePrefix:  
NameSuffix:  
Credential: PT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 790 REMINGTON BLVD
Address2:  
City: BOLINGBROOK
State: IL
PostalCode: 604404909
CountryCode: US
TelephoneNumber: (630) 296-2223
FaxNumber: 6307599510
Practice Location
Address1: 1877 CHEROKEE AVE SW
Address2:  
City: CULLMAN
State: AL
PostalCode: 350555547
CountryCode: US
TelephoneNumber: 2567271701
FaxNumber: 2568413142
Other Information
ProviderEnumerationDate: 05/29/2007
LastUpdateDate: 06/09/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225100000XPTH4967ALY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

ID Information
IDTypeStateIssuerDescription
100301718701ALINDIVIDUAL NPIOTHER


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