Provider Demographics
NPI:1063838522
Name:MEDICAL AND REHABABILITATION CENTER OF CHICAGO LLC
Entity Type:Organization
Organization Name:MEDICAL AND REHABABILITATION CENTER OF CHICAGO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MALCOM
Authorized Official - Middle Name:D
Authorized Official - Last Name:HERZOG
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:708-380-7028
Mailing Address - Street 1:5241 S CICERO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60632-4967
Mailing Address - Country:US
Mailing Address - Phone:773-284-8811
Mailing Address - Fax:773-284-6431
Practice Address - Street 1:5241 S CICERO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-4967
Practice Address - Country:US
Practice Address - Phone:773-284-8811
Practice Address - Fax:773-284-6431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-07
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL616225000OtherDOWL