Basic Information
| Provider Information | |||||||||
| NPI: | 1881738060 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDWEST PHYSICAL THERAPY CNTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 PARK BLVD | ||||||||
| Address2: | SUITE LL80C | ||||||||
| City: | ITASCA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601433121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302858007 | ||||||||
| FaxNumber: | 6302858017 | ||||||||
| Practice Location | |||||||||
| Address1: | 1990 LARKIN AVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | ELGIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601235827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472899800 | ||||||||
| FaxNumber: | 8472899804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2007 | ||||||||
| LastUpdateDate: | 08/18/2008 | ||||||||
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| AuthorizedOfficialLastName: | DEOL | ||||||||
| AuthorizedOfficialFirstName: | DEVINDER | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6302858007 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 01621171 | 01 | IL | BCBS PROVIDER NUMBER | OTHER |