Provider Demographics
NPI:1548497803
Name:HEITZIG, KRISTOPHER JOHN (DPT)
Entity type:Individual
Prefix:
First Name:KRISTOPHER
Middle Name:JOHN
Last Name:HEITZIG
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2233
Mailing Address - Fax:
Practice Address - Street 1:735 HIGHGROVE PL
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2520
Practice Address - Country:US
Practice Address - Phone:815-226-4365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-15
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070017180225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP01061416OtherMEDICARE RAILROAD
IL209796004Medicare PIN
IL216860009Medicare PIN
IL202845037Medicare PIN
IL212622002Medicare PIN
IL202845154Medicare PIN
IL214708004Medicare PIN
IL212989004Medicare PIN