1790738409 NPI number — FUNCTIONAL PHYSICAL THERAPY, INC

Table of content: (NPI 1790738409)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790738409 NPI number — FUNCTIONAL PHYSICAL THERAPY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FUNCTIONAL PHYSICAL THERAPY, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790738409
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
152 S BLOOMINGDALE RD
Provider Second Line Business Mailing Address:
UNIT 101
Provider Business Mailing Address City Name:
BLOOMINGDALE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60108-1481
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-893-5534
Provider Business Mailing Address Fax Number:
630-893-5527

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
369 W ARMY TRAIL RD
Provider Second Line Business Practice Location Address:
UNIT 14
Provider Business Practice Location Address City Name:
BLOOMINGDALE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60108-2358
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-893-5534
Provider Business Practice Location Address Fax Number:
630-893-5527
Provider Enumeration Date:
05/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FEDORSKI
Authorized Official First Name:
TIM
Authorized Official Middle Name:
FRANCIS
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
630-893-5534

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  070-011136 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02232938 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: DH0131 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: P00478856 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 352586282001 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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