Basic Information
Provider Information | |||||||||
NPI: | 1407964984 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KUNZE | ||||||||
FirstName: | LUCAS | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 205 W WACKER DR | ||||||||
Address2: | SUITE 1020 | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606061216 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3126400329 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3616 N MAIN ST | ||||||||
Address2: |   | ||||||||
City: | ROCKFORD | ||||||||
State: | IL | ||||||||
PostalCode: | 611032159 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8158775932 | ||||||||
FaxNumber: | 8158776302 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/26/2006 | ||||||||
LastUpdateDate: | 12/17/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 10301024 | WI | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 0604410001 | 01 | WI | DMERC | OTHER | 40447500 | 05 | WI |   | MEDICAID | P00214353 | 01 | WI | RAILROAD MEDICARE NUMBER | OTHER | K22207 | 01 | IL | MEDICARE NUMBER | OTHER |