Basic Information
| Provider Information | |||||||||
| NPI: | 1881922680 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRUNNER | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | |||||||||
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| Credential: | MPT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | SILVERSTEIN | ||||||||
| OtherFirstName: | JILL | ||||||||
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| OtherCredential: | MPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3233 W ADDISON ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606184328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7734780496 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2009 | ||||||||
| LastUpdateDate: | 03/26/2015 | ||||||||
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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 | 070015482 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P01419767 | 01 | IL | RR MEDICARE | OTHER |