Provider Demographics
NPI:1003135526
Name:WESTERN REHABILITATION AND PAIN MANAGEMENT, S.C.
Entity Type:Organization
Organization Name:WESTERN REHABILITATION AND PAIN MANAGEMENT, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMED
Authorized Official - Middle Name:N
Authorized Official - Last Name:SIDDIQUI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:630-873-5425
Mailing Address - Street 1:PO BOX 5978
Mailing Address - Street 2:
Mailing Address - City:VILLA PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60181-5312
Mailing Address - Country:US
Mailing Address - Phone:630-873-5425
Mailing Address - Fax:630-620-1196
Practice Address - Street 1:2340 S HIGHLAND AVE
Practice Address - Street 2:SUITE 370
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-5397
Practice Address - Country:US
Practice Address - Phone:630-873-5425
Practice Address - Fax:630-620-1196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-24
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036082891208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL3784Medicare PIN