Basic Information
| Provider Information | |||||||||
| NPI: | 1780990051 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHERN ILLINOIS UNIVERSITY | ||||||||
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| OtherOrganizationName: | SPORTS MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1525 W LINCOLN HWY | ||||||||
| Address2: | SUITE 170-NIU ATHLETIC TRAINING | ||||||||
| City: | DEKALB | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601153989 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157530211 | ||||||||
| FaxNumber: | 8157531402 | ||||||||
| Practice Location | |||||||||
| Address1: | 1525 W LINCOLN HWY | ||||||||
| Address2: | SUITE 170-NIU ATHLETIC TRAINING | ||||||||
| City: | DEKALB | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601153989 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157530211 | ||||||||
| FaxNumber: | 8157531402 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2010 | ||||||||
| LastUpdateDate: | 08/25/2010 | ||||||||
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| AuthorizedOfficialLastName: | VOORHIS | ||||||||
| AuthorizedOfficialFirstName: | PHILLIP | ||||||||
| AuthorizedOfficialMiddleName: | EDWARD | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT ATHLETIC DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8157530211 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | ATC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | 096000344 | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
No ID Information.