Basic Information
Provider Information | |||||||||
NPI: | 1134307192 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OCCUPATIONAL HEALTH CENTERS OF ILLINOIS PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CONCENTRA MEDICAL CENTERS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5080 SPECTRUM DRIVE | ||||||||
Address2: | SUITE 1200 WEST | ||||||||
City: | ADDISON | ||||||||
State: | TX | ||||||||
PostalCode: | 750014625 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9723648000 | ||||||||
FaxNumber: | 2147754406 | ||||||||
Practice Location | |||||||||
Address1: | 501 S GRACE ST | ||||||||
Address2: |   | ||||||||
City: | ADDISON | ||||||||
State: | IL | ||||||||
PostalCode: | 60101 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6305434040 | ||||||||
FaxNumber: | 6305431050 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/01/2008 | ||||||||
LastUpdateDate: | 09/13/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | YALDO | ||||||||
AuthorizedOfficialFirstName: | RAAD | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9723648000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Health Service | 261QP2000X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | 261QX0100X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Occupational Medicine | 261Q00000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
No ID Information.