1003036344 NPI number — PHYSICAL THERAPY CLINIC OF CHICAGO, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003036344 NPI number — PHYSICAL THERAPY CLINIC OF CHICAGO, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICAL THERAPY CLINIC OF CHICAGO, P.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:
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:
1003036344
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6135 W BELMONT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60634-5165
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-237-7827
Provider Business Mailing Address Fax Number:
773-237-7826

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6135 W BELMONT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60634-5165
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-237-7827
Provider Business Practice Location Address Fax Number:
773-237-7826
Provider Enumeration Date:
04/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PRUS
Authorized Official First Name:
JAROSLAW
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
773-237-7827

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , 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: 01633218 . This is a "BLUECROSS BLUE SHIELD OF" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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