Victor Erude Lidaywa, DPT

Primary specialty

Physical Therapy Clinic/CenterTaxonomy code 261QP2000X

License

070.017800 Issued in IL

Practice address

1701 W Jackson St
Ste C
Macomb, IL 61455-3175

Phone

(309) 331-3590

NPI assigned

Jan 23, 2019

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in IL

Enrollment records 1

Specialty

Physical Therapist in Private Practice

Education

Other, 2009

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Age Rehab & Medical Fitness

  • Physical Therapy Clinic/Center
  • Macomb, IL
  • NPI 1184188443
  NPD (past) Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1548201600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1549065600000",
    "number": "1083178198",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "305 E SUMMIT ST",
            "city": "MACOMB",
            "state": "IL",
            "postal_code": "614553223",
            "telephone_number": "309-837-1748"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1701 W JACKSON ST",
            "address_2": "STE C",
            "city": "MACOMB",
            "state": "IL",
            "postal_code": "614553175",
            "telephone_number": "309-331-3590"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "LIDAYWA",
        "first_name": "VICTOR",
        "middle_name": "ERUDE",
        "credential": "DPT",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2019-01-23",
        "last_updated": "2019-02-02",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "IL",
            "license": "070.017800",
            "primary": false
        },
        {
            "code": "261QP2000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Physical Therapy",
            "state": "IL",
            "license": "070.017800",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Physical Therapy Clinic/Center in Macomb, IL
• Providers in Macomb, IL by specialty
• Physical Therapy Clinic/Center in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 2, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.