Provider Demographics
NPI:1932410784
Name:PAMFILO, JANSSEN BARLAAN
Entity type:Individual
Prefix:
First Name:JANSSEN
Middle Name:BARLAAN
Last Name:PAMFILO
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 1:100 E IRVING PARK RD
Mailing Address - Street 2:STE. #107
Mailing Address - City:ROSELLE
Mailing Address - State:IL
Mailing Address - Zip Code:60172-2048
Mailing Address - Country:US
Mailing Address - Phone:630-429-0009
Mailing Address - Fax:630-429-0011
Practice Address - Street 1:5440 N CUMBERLAND AVE STE A101
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60656-4701
Practice Address - Country:US
Practice Address - Phone:774-444-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-27
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070017018225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208325006Medicare PIN