Provider Demographics
NPI:1598289142
Name:BUMGARDNER, KEITH FRANKLIN JR (DPT)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:FRANKLIN
Last Name:BUMGARDNER
Suffix:JR
Gender:
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:849 S ROUTE 51 STE D
Mailing Address - Street 2:
Mailing Address - City:FORSYTH
Mailing Address - State:IL
Mailing Address - Zip Code:62535-8808
Mailing Address - Country:US
Mailing Address - Phone:217-872-2244
Mailing Address - Fax:
Practice Address - Street 1:849 S ROUTE 51 STE D
Practice Address - Street 2:
Practice Address - City:FORSYTH
Practice Address - State:IL
Practice Address - Zip Code:62535-8808
Practice Address - Country:US
Practice Address - Phone:217-872-2244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-26
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY007133225100000X
IL070.024270225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist