Provider Demographics
NPI:1053516088
Name:WIRTH, SCOTT M (DPT)
Entity type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:M
Last Name:WIRTH
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 1:19720 W. RT 102
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60481-9743
Mailing Address - Country:US
Mailing Address - Phone:217-390-3190
Mailing Address - Fax:
Practice Address - Street 1:635 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:WILLOWBROOK
Practice Address - State:IL
Practice Address - Zip Code:60527-5603
Practice Address - Country:US
Practice Address - Phone:630-455-6630
Practice Address - Fax:630-455-6631
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2011-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-015955225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00915453OtherMEDICARE RAILROAD
IL2028450018Medicare PIN