Sudsvat Gaewjundee, P.T. – Physical Therapist

Key facts

NPI: 1255535019
Entity type: Individual (NPI type 1)
Primary specialty: Physical Therapist 225100000X
License: 070007343 (IL)
Practice address: 100 9TH St
Mena, AR 71953-3026
Phone: (479) 394-2617
Fax: (479) 243-0107
NPI assigned: Jun 13, 2007
Sex: Female
Sole proprietor: No

Medicare participation

Medicare fee-for-service enrollment: Not listed in the public Medicare enrollment file

National Provider Directory

Medicare enrollment (NPD): No

State licenses

License	State	Type	Specialty
PT 2532	AR	MD	Physical Therapist
070007343	IL	MD	Physical Therapist

Specialties & licenses

Specialty (taxonomy)	Code	License	State	Primary
Physical Therapist	225100000X	PT 2532	AR
Physical Therapist	225100000X	070007343	IL	Yes

Addresses

Primary practice location

100 9TH St
Mena, AR 71953-3026

Mailing address

1145 Museum Blvd Unit 405
Vernon Hills, IL 60061-3169
Phone (479) 227-0179

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Mar 12, 2020.

{
    "created_epoch": "1181692800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1583971200000",
    "number": "1255535019",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1145 MUSEUM BLVD UNIT 405",
            "city": "VERNON HILLS",
            "state": "IL",
            "postal_code": "600613169",
            "telephone_number": "479-227-0179"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 9TH ST",
            "city": "MENA",
            "state": "AR",
            "postal_code": "719533026",
            "telephone_number": "479-394-2617",
            "fax_number": "479-243-0107"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "GAEWJUNDEE",
        "first_name": "SUDSVAT",
        "name_prefix": "Ms.",
        "credential": "P.T.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2007-06-13",
        "last_updated": "2020-03-12",
        "certification_date": "2020-03-12",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "AR",
            "license": "PT 2532",
            "primary": false
        },
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "IL",
            "license": "070007343",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Mena, AR

All providers in Mena, AR · Physical Therapist in Arkansas

Sources for this page

NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 12, 2020. Information in NPPES is self-reported and not verified by CMS.
NUCC Health Care Provider Taxonomy: specialty names.
National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.