1326150624 NPI number — SPORTS PHYSICAL THERAPY & REHAB SPECIALISTS, S.C.

Table of content: (NPI 1326150624)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326150624 NPI number — SPORTS PHYSICAL THERAPY & REHAB SPECIALISTS, S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPORTS PHYSICAL THERAPY & REHAB SPECIALISTS, S.C.
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:
ATHLETICO PHYSICAL THERAPY
Provider Other Organization Name Type Code:
3
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:
1326150624
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/11/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
625 ENTERPRISE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK BROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60523-8813
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-575-1980
Provider Business Mailing Address Fax Number:
630-928-5080

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3915 30TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENOSHA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53144-1957
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-657-0222
Provider Business Practice Location Address Fax Number:
262-657-7190
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FERNANDEZ
Authorized Official First Name:
JUANA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CREDENTIALING MANAGER
Authorized Official Telephone Number:
630-575-1980

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 000085940 . This is a "MEDICARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 000086040 . This is a "MEDICARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 4919795 . This is a "BCBS OF IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CG8674 . This is a "RAILROAD MEDICARE NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: WI2660 . This is a "MEDICARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 40415400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: CJ6927 . This is a "RAILROAD MEDICARE NUMBER" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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