Provider Demographics
NPI:1780758615
Name:MURILLO, MARIDREN S (LPT)
Entity type:Individual
Prefix:
First Name:MARIDREN
Middle Name:S
Last Name:MURILLO
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E IRVING PARK RD
Mailing Address - Street 2:STE. #107
Mailing Address - City:ROSELLE
Mailing Address - State:IL
Mailing Address - Zip Code:60172-2048
Mailing Address - Country:US
Mailing Address - Phone:630-439-0009
Mailing Address - Fax:630-439-0011
Practice Address - Street 1:1170 PARK AVE W
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-2203
Practice Address - Country:US
Practice Address - Phone:847-433-3700
Practice Address - Fax:847-433-1699
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-012209225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00134552Medicare ID - Type UnspecifiedRAIL ROAD MEDICARE LOC16
ILK03960Medicare ID - Type UnspecifiedMCARE LOC16
ILK03959Medicare ID - Type UnspecifiedMCARE LOC15
IL6074150001Medicare NSC