Active NPI
Kyle Boudreau, P.T.
- Physical Therapist
- Bourbonnais, IL
National Provider Identifier
1336594282
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapist
- License
- 070020042
- Practice address
- 557 Main St NW
Bourbonnais, IL 60914-2305 - Phone
- (815) 839-2090
- Fax
- (815) 209-9304
- NPI assigned
- Apr 28, 2016
- Last updated
- Aug 4, 2022
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapist | 225100000X | 070020042 | IL | Primary |
Addresses
Primary practice location
557 Main St NW
Bourbonnais, IL 60914-2305
Mailing address
1311 Mamaroneck Ave Ste 140
White Plains, NY 10605-5224
Phone (914) 294-4050
Other practice location 1
1397 Main St Ste A
Crete, IL 60417-2951
Phone (708) 367-8050
Other practice location 2
1511 N Convent St
Bourbonnais, IL 60914
Phone (815) 401-5102
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Panoptic Physical Therapy LLC | Physical Medicine & Rehabilitation | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
-
dba Panoptic Physical Therapy - Bourbonnais
- Physical Medicine & Rehabilitation Physician
- Bourbonnais, IL
- NPI 1740843267
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1461801600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1659571200000",
"number": "1336594282",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1311 MAMARONECK AVE STE 140",
"city": "WHITE PLAINS",
"state": "NY",
"postal_code": "106055224",
"telephone_number": "914-294-4050",
"fax_number": "815-401-5103"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "557 MAIN ST NW",
"city": "BOURBONNAIS",
"state": "IL",
"postal_code": "609142305",
"telephone_number": "815-839-2090",
"fax_number": "815-209-9304"
}
],
"practiceLocations": [
{
"address_1": "1397 Main St Ste A",
"address_purpose": "LOCATION",
"city": "Crete",
"state": "IL",
"postal_code": "604172951",
"country_code": "US",
"telephone_number": "708-367-8050",
"country_name": "United States",
"address_type": "DOM"
},
{
"address_1": "1511 N Convent St",
"address_purpose": "LOCATION",
"city": "Bourbonnais",
"state": "IL",
"postal_code": "60914",
"country_code": "US",
"telephone_number": "815-401-5102",
"fax_number": "815-401-5103",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"last_name": "BOUDREAU",
"first_name": "KYLE",
"credential": "P.T.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2016-04-28",
"last_updated": "2022-08-04",
"certification_date": "2022-08-04",
"status": "A"
},
"taxonomies": [
{
"code": "225100000X",
"taxonomy_group": "",
"desc": "Physical Therapist",
"state": "IL",
"license": "070020042",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Bourbonnais, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 4, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.