Provider Demographics
NPI:1023218260
Name:ORTHOPEDIC, SPORTS & REHABILITATION CENTER, LTD.
Entity Type:Organization
Organization Name:ORTHOPEDIC, SPORTS & REHABILITATION CENTER, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:NIGAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-397-6276
Mailing Address - Street 1:6957 OLDE CREEK RD
Mailing Address - Street 2:SUITE #3400
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-7416
Mailing Address - Country:US
Mailing Address - Phone:815-397-6276
Mailing Address - Fax:815-397-2266
Practice Address - Street 1:6957 OLDE CREEK RD
Practice Address - Street 2:SUITE #3400
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-7416
Practice Address - Country:US
Practice Address - Phone:815-397-6276
Practice Address - Fax:815-397-2266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-24
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207X00000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty