Basic Information
| Provider Information | |||||||||
| NPI: | 1366585291 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCHENRY MEDICAL CENTER SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 202 S IL ROUTE 31 | ||||||||
| Address2: | |||||||||
| City: | MCHENRY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600504018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153441192 | ||||||||
| FaxNumber: | 8153448070 | ||||||||
| Practice Location | |||||||||
| Address1: | 202 S IL ROUTE 31 | ||||||||
| Address2: | |||||||||
| City: | MCHENRY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600504018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153441192 | ||||||||
| FaxNumber: | 8153448070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 12/26/2012 | ||||||||
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| AuthorizedOfficialLastName: | HARTLETT | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | JAMES | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8153441192 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.C. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 111N00000X | 038-005325 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor |
No ID Information.