Provider Demographics
NPI:1063813517
Name:MIDWEST SPORTS MEDICINE
Entity Type:Organization
Organization Name:MIDWEST SPORTS MEDICINE
Other - Org Name:THE CENTER FOR PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:LETICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PEDRAZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-437-9889
Mailing Address - Street 1:901 BIESTERFIELD RD STE 306
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-7324
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:901 BIESTERFIELD RD STE 306
Practice Address - Street 2:
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-7324
Practice Address - Country:US
Practice Address - Phone:847-437-1230
Practice Address - Fax:847-437-9023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-15
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.021091261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy