Provider Demographics
NPI:1114138732
Name:HEIDERSCHEIT, BRYAN (PT, PHD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:
Last Name:HEIDERSCHEIT
Suffix:
Gender:M
Credentials:PT, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 SCIENCE DR
Mailing Address - Street 2:UW SPORTS REHABILITATION
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-1074
Mailing Address - Country:US
Mailing Address - Phone:608-263-4765
Mailing Address - Fax:
Practice Address - Street 1:621 SCIENCE DR
Practice Address - Street 2:UW SPORTS REHABILITATION
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-1074
Practice Address - Country:US
Practice Address - Phone:608-263-4765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4896-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4896-024OtherPHYSICAL THERAPIST