Provider Demographics
NPI:1417128901
Name:GENGENBACHER, KURT A (DPT,CSCS)
Entity type:Individual
Prefix:
First Name:KURT
Middle Name:A
Last Name:GENGENBACHER
Suffix:
Gender:M
Credentials:DPT,CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:3082 CATON FARM RD
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-1455
Practice Address - Country:US
Practice Address - Phone:815-577-9936
Practice Address - Fax:815-577-9938
Is Sole Proprietor?:No
Enumeration Date:2008-03-12
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-016253225100000X
DEJ1-0002601225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP01061414OtherMEDICARE RAILROAD
IL202845005Medicare PIN
ILP01061414OtherMEDICARE RAILROAD
IL202845216Medicare PIN
ILR01877Medicare PIN
ILK50346Medicare PIN