Basic Information
| Provider Information | |||||||||
| NPI: | 1457307498 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WELDER | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | PAUL | ||||||||
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| Credential: | MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 27 S WESTERN AVE STE B | ||||||||
| Address2: | |||||||||
| City: | CARPENTERSVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601101715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 03/06/2015 | ||||||||
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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 | 6519024 | WI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 070011738 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 33874990001 | 05 | IL | MEDICAID | IL6238010 | 01 | IL | MEDICARE | OTHER | 00485940 | 01 | WI | MEDICARE WI | OTHER | IL6237010 | 01 | IL | MEDICARE | OTHER | IL6697011 | 01 | IL | MEDICARE | OTHER | 40462600 | 01 | WI | MEDICAID WI | OTHER |