Basic Information
| Provider Information | |||||||||
| NPI: | 1699786558 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDWEST PHYSICAL THERAPY CENTER, LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 E STATE PKWY | ||||||||
| Address2: | SUITE E | ||||||||
| City: | SCHAUMBURG | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601734569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302858007 | ||||||||
| FaxNumber: | 6302858017 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 E STATE PKWY | ||||||||
| Address2: | SUITE E | ||||||||
| City: | SCHAUMBURG | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601734569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302858007 | ||||||||
| FaxNumber: | 6302858017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 07/10/2012 | ||||||||
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| AuthorizedOfficialLastName: | KRUSE | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PHYSICAL THERAPY | ||||||||
| AuthorizedOfficialTelephone: | 6302858007 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 001621171 | 01 | IL | BCBS PROVIDER NUMBER | OTHER |