Provider Demographics
NPI:1346958543
Name:DEMARTINO, MAX RYAN (DPT)
Entity type:Individual
Prefix:
First Name:MAX
Middle Name:RYAN
Last Name:DEMARTINO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 BUTTERFIELD RD STE 1600
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:348 COOLEY ST UNIT 10
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01128-1144
Practice Address - Country:US
Practice Address - Phone:413-355-5700
Practice Address - Fax:413-526-9961
Is Sole Proprietor?:No
Enumeration Date:2022-11-07
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA225100000X
CT012906225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist