Provider Demographics
NPI:1992916605
Name:DEITERS, HERBERT (PT)
Entity type:Individual
Prefix:
First Name:HERBERT
Middle Name:
Last Name:DEITERS
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 1:2160 S 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-3328
Mailing Address - Country:US
Mailing Address - Phone:888-584-7888
Mailing Address - Fax:
Practice Address - Street 1:15750 MARIAN DR
Practice Address - Street 2:
Practice Address - City:HOMER GLEN
Practice Address - State:IL
Practice Address - Zip Code:60491-6200
Practice Address - Country:US
Practice Address - Phone:708-645-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070015746225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1619908OtherBCBS OF IL
IL1623066OtherBCBS PROVIDER #
IL367885100OtherUS DEPT OF LABOR
IL367885100OtherUS DEPT OF LABOR
IL1619908OtherBCBS OF IL
IL568150Medicare UPIN
IL1623066OtherBCBS PROVIDER #
IL200852Medicare ID - Type UnspecifiedMEDICARE GROUP #
ILR02551Medicare PIN
IL568080Medicare PIN
ILR02553Medicare PIN