Provider Demographics
NPI:1043428832
Name:ROSCOE PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:ROSCOE PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:MCKINLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:815-623-9700
Mailing Address - Street 1:5003 HONONEGAH RD
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-8682
Mailing Address - Country:US
Mailing Address - Phone:815-623-9700
Mailing Address - Fax:815-623-9722
Practice Address - Street 1:5003 HONONEGAH RD
Practice Address - Street 2:
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073-8682
Practice Address - Country:US
Practice Address - Phone:815-623-9700
Practice Address - Fax:815-623-9722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
10132155OtherBLUE CROSS BLUE SHIELD
IL211498Medicare ID - Type Unspecified