1720104110 NPI number — REHAB MANAGEMENT SPECIALISTS, PC

Table of content: (NPI 1720104110)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720104110 NPI number — REHAB MANAGEMENT SPECIALISTS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REHAB MANAGEMENT SPECIALISTS, PC
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:
1720104110
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12172 S STATE ROUTE 47 STE 319
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUNTLEY
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60142-9619
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-804-9332
Provider Business Mailing Address Fax Number:
815-943-0196

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
109 W FRONT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARVARD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60033-2833
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-804-9332
Provider Business Practice Location Address Fax Number:
815-943-0196
Provider Enumeration Date:
03/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GENTRY
Authorized Official First Name:
GEOFFREY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
312-804-9332

Provider Taxonomy Codes

  • Taxonomy code: 2251X0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1634788 . This is a "BLUE CROSS BLUE SHEILD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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