1861503542 NPI number — ATHLETIC AND THERAPEUTIC INSTITUTE OF BOURBONNAIS, LLC

Table of content: (NPI 1861503542)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861503542 NPI number — ATHLETIC AND THERAPEUTIC INSTITUTE OF BOURBONNAIS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ATHLETIC AND THERAPEUTIC INSTITUTE OF BOURBONNAIS, 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:
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:
1861503542
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/28/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4947 PAYSHERE CIRCLE
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:
60674-4064
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-783-2001
Provider Business Mailing Address Fax Number:
630-783-0117

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1275 N CONVENT ST
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
BOURBONNAIS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60914-8210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-936-1855
Provider Business Practice Location Address Fax Number:
815-936-6097
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MEYER
Authorized Official First Name:
WADE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
VP 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: 7725634 . This is a "AETNA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 610128400 . This is a "DEPARTMENT OF LABOR PROVIDER NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 04632047 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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