Provider Demographics
NPI:1083769475
Name:PHYSICAL THERAPISTS CLINIC, LTD
Entity Type:Organization
Organization Name:PHYSICAL THERAPISTS CLINIC, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:BARBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-245-1325
Mailing Address - Street 1:1440 W WALNUT ST
Mailing Address - Street 2:SUITE2
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-1143
Mailing Address - Country:US
Mailing Address - Phone:217-245-1325
Mailing Address - Fax:217-243-6903
Practice Address - Street 1:1440 W WALNUT ST
Practice Address - Street 2:SUITE2
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-1143
Practice Address - Country:US
Practice Address - Phone:217-245-1325
Practice Address - Fax:217-243-6903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
IL203000094332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1558480418Medicaid
IL005415281OtherBCBS
IL0179880001Medicare NSC
ILCG5289Medicare PIN