Provider Demographics
NPI:1447294053
Name:MAHER, EDWARD J (PT, AMPT, OCS, CMPT)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:J
Last Name:MAHER
Suffix:
Gender:M
Credentials:PT, AMPT, OCS, CMPT
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:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:625 E SAINT PAUL AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-5907
Practice Address - Country:US
Practice Address - Phone:414-272-9595
Practice Address - Fax:414-272-9594
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4910-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1447294053OtherWI MEDICAID
WIP01347424OtherRAILROAD MEDICARE
WI1447294053OtherWI MEDICAID
WI830420031Medicare PIN