Basic Information
Provider Information | |||||||||
NPI: | 1942481411 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ATHLETIC & THERAPEUTIC INSTITUTE OF NAPERVILLE, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ATI PHYSICAL THERAPY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4947 PAYSPHERE CIR | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606740049 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6307832001 | ||||||||
FaxNumber: | 6306330117 | ||||||||
Practice Location | |||||||||
Address1: | 18W431 ROOSEVELT RD | ||||||||
Address2: |   | ||||||||
City: | LOMBARD | ||||||||
State: | IL | ||||||||
PostalCode: | 601484142 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6306201511 | ||||||||
FaxNumber: | 6306201588 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/26/2007 | ||||||||
LastUpdateDate: | 03/04/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BOGOVICH | ||||||||
AuthorizedOfficialFirstName: | MARK | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 6302962222 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 356148908 | 01 | IL | DEPARTMENT OF LABOR PROVIDER NUMBER | OTHER |