Basic Information
| Provider Information | |||||||||
| NPI: | 1780601690 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHWEST REHABILITATION, S.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 388320 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606388320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737674600 | ||||||||
| FaxNumber: | 7737678320 | ||||||||
| Practice Location | |||||||||
| Address1: | 12251 S 80TH AVE | ||||||||
| Address2: | |||||||||
| City: | PALOS HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604631256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7089235055 | ||||||||
| FaxNumber: | 7089235058 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2006 | ||||||||
| LastUpdateDate: | 08/26/2009 | ||||||||
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| AuthorizedOfficialLastName: | MOCHIZUKI | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7089235055 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 01620954 | 01 | IL | BLUE SHIELD | OTHER |