Provider Demographics
NPI:1053078758
Name:PASTRICK, MARK PHILLIP (PT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:PHILLIP
Last Name:PASTRICK
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 1:15430 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-4661
Mailing Address - Country:US
Mailing Address - Phone:708-923-5050
Mailing Address - Fax:708-226-2528
Practice Address - Street 1:15430 WEST AVE
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-4661
Practice Address - Country:US
Practice Address - Phone:708-923-5050
Practice Address - Fax:708-226-2528
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-17
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.006519225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist