Basic Information
| Provider Information | |||||||||
| NPI: | 1588989057 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH SUBURBAN PHYSICAL THERAPY, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1836 OSLO CT | ||||||||
| Address2: | |||||||||
| City: | MUNDELEIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600604869 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3021 FALLING WATERS BLVD | ||||||||
| Address2: | |||||||||
| City: | LINDENHURST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600466793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306743210 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2010 | ||||||||
| LastUpdateDate: | 03/28/2010 | ||||||||
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| AuthorizedOfficialLastName: | BAGLEY | ||||||||
| AuthorizedOfficialFirstName: | RYAN | ||||||||
| AuthorizedOfficialMiddleName: | KENNETH | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6306743210 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070014971 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.