Basic Information
| Provider Information | |||||||||
| NPI: | 1376692319 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCALLISTER | ||||||||
| FirstName: | POONAM | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1408 SEARLE DR | ||||||||
| Address2: | |||||||||
| City: | NORMAL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617612870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3094542495 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2200 FORT JESSE RD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | NORMAL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617616286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3094541616 | ||||||||
| FaxNumber: | 3094545167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070-007930 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 100044415-62762-01 | 05 | IL | MEDICAID |