Provider Demographics
NPI:1992977185
Name:IMMEKUS, EDWARD GABRIEL (PT)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:GABRIEL
Last Name:IMMEKUS
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 1:1808 W BELTLINE HWY
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53713-2334
Mailing Address - Country:US
Mailing Address - Phone:608-250-1497
Mailing Address - Fax:608-250-1384
Practice Address - Street 1:10 TOWER DR
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-1239
Practice Address - Country:US
Practice Address - Phone:608-825-3500
Practice Address - Fax:608-825-3598
Is Sole Proprietor?:No
Enumeration Date:2008-03-27
Last Update Date:2021-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10962-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI60582OtherDEAN HEALTH INSURANCE