Provider Demographics
NPI:1932454634
Name:MARQUEZ, MICHAEL LADRA
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LADRA
Last Name:MARQUEZ
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 1:5000 SOUTH 5TH AVE.
Mailing Address - Street 2:EDWARD HINES JR. VA HOSPITAL
Mailing Address - City:HINES
Mailing Address - State:IL
Mailing Address - Zip Code:60141
Mailing Address - Country:US
Mailing Address - Phone:708-202-3800
Mailing Address - Fax:
Practice Address - Street 1:5000 SOUTH 5TH AVE.
Practice Address - Street 2:EDWARD HINES JR. VA HOSPITAL
Practice Address - City:HINES
Practice Address - State:IL
Practice Address - Zip Code:60141
Practice Address - Country:US
Practice Address - Phone:708-202-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070018902225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist