1457462053 NPI number — ATHLETIC AND THERAPEUTIC INSTITUTE OF NAPERVILLE, LLC

Table of content: (NPI 1457462053)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457462053 NPI number — ATHLETIC AND THERAPEUTIC INSTITUTE OF NAPERVILLE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ATHLETIC AND THERAPEUTIC INSTITUTE OF NAPERVILLE, LLC
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:
6
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:
1457462053
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4947 PAYSPHERE CIR
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:
60674-0049
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-296-2223
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4511 STATE ROUTE 71
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OSWEGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60543-7416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-554-7815
Provider Business Practice Location Address Fax Number:
630-554-4849
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCGIVERN
Authorized Official First Name:
LYNN
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF COMPLIANCE OFFICER
Authorized Official Telephone Number:
630-296-2222

Provider Taxonomy Codes

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

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

  • Identifier: 04732021 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 611827600 . This is a "DEPARTMENT OF LABOR PROVIDER NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 7400622 . This is a "AETNA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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