Provider Demographics
NPI:1811442064
Name:MATHISON, LUKE
Entity type:Individual
Prefix:
First Name:LUKE
Middle Name:
Last Name:MATHISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:939 W MADISON ST
Mailing Address - Street 2:STE 103
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-2638
Mailing Address - Country:US
Mailing Address - Phone:312-243-9350
Mailing Address - Fax:773-913-0602
Practice Address - Street 1:225 S SANGAMON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-3196
Practice Address - Country:US
Practice Address - Phone:312-243-9350
Practice Address - Fax:773-913-0602
Is Sole Proprietor?:No
Enumeration Date:2016-08-17
Last Update Date:2016-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070022430225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILAPPLIED FORMedicaid
ILAPPLIED FORMedicare PIN
ILAPPLIED FORMedicaid