Basic Information
| Provider Information | |||||||||
| NPI: | 1710150453 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COVENANT PHYSIATRY,SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 967 | ||||||||
| Address2: | |||||||||
| City: | TINLEY PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604770967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7085326029 | ||||||||
| FaxNumber: | 7085326095 | ||||||||
| Practice Location | |||||||||
| Address1: | 1590 W ALGONQUIN RD | ||||||||
| Address2: | SUITE 167 | ||||||||
| City: | HOFFMAN ESTATES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601921575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478526478 | ||||||||
| FaxNumber: | 8473821646 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2008 | ||||||||
| LastUpdateDate: | 06/29/2015 | ||||||||
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| AuthorizedOfficialLastName: | MEESALA | ||||||||
| AuthorizedOfficialFirstName: | SANDHYA | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8478526478 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 036110423 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 0001638924 | 01 | IL | BS# | OTHER | 036110423 | 05 | IL | MEDICAID |