Basic Information
| Provider Information | |||||||||
| NPI: | 1053516088 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIRTH | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19720 W. RT 102 | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604819743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173903190 | ||||||||
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| Practice Location | |||||||||
| Address1: | 635 EXECUTIVE DR | ||||||||
| Address2: | |||||||||
| City: | WILLOWBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605275603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6304556630 | ||||||||
| FaxNumber: | 6304556631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2007 | ||||||||
| LastUpdateDate: | 05/27/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070-015955 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P00915453 | 01 | IL | MEDICARE RAILROAD | OTHER |