Provider Demographics
NPI:1902941859
Name:FERNANDEZ, RICARDO (PT)
Entity Type:Individual
Prefix:
First Name:RICARDO
Middle Name:
Last Name:FERNANDEZ
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 1:6701 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2105
Mailing Address - Country:US
Mailing Address - Phone:708-599-5000
Mailing Address - Fax:
Practice Address - Street 1:25 HERITAGE WAY
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3100
Practice Address - Country:US
Practice Address - Phone:406-407-7990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070005926225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00943074OtherMEDICARE RAILROAD
ILP00943074OtherMEDICARE RAILROAD
IL216859157Medicare PIN