Provider Demographics
NPI:1982662870
Name:BLONDHEIM, IRA L (PT)
Entity type:Individual
Prefix:
First Name:IRA
Middle Name:L
Last Name:BLONDHEIM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 YORK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1925
Mailing Address - Country:US
Mailing Address - Phone:630-575-1980
Mailing Address - Fax:410-648-4878
Practice Address - Street 1:411 E IRELAND RD STE 400
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-2681
Practice Address - Country:US
Practice Address - Phone:574-231-8950
Practice Address - Fax:574-231-8955
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05014436A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515-20068OtherBCBS NUMBER
AL051520068Medicare ID - Type UnspecifiedMEDICARE