Provider Demographics
NPI:1053646398
Name:PREMIERE PHYSICAL THERAPY & SPORTS INJURY REHABILITATION LLC
Entity Type:Organization
Organization Name:PREMIERE PHYSICAL THERAPY & SPORTS INJURY REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-744-8000
Mailing Address - Street 1:2901 OLD JACKSONVILLE RD STE C
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-7437
Mailing Address - Country:US
Mailing Address - Phone:217-793-0000
Mailing Address - Fax:
Practice Address - Street 1:2901 OLD JACKSONVILLE RD STE C
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-7437
Practice Address - Country:US
Practice Address - Phone:217-793-0000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-05
Last Update Date:2009-10-05
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
IL8421396OtherBCBS
IL208419Medicare PIN
IL5394810001Medicare NSC