Provider Demographics
NPI:1093775561
Name:MEMORIAL INDUSTRIAL REHABILITATION OF JACKSONVILLE
Entity Type:Organization
Organization Name:MEMORIAL INDUSTRIAL REHABILITATION OF JACKSONVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:T
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-788-3340
Mailing Address - Street 1:901 W MORTON AVE
Mailing Address - Street 2:SUITE 16A
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-3146
Mailing Address - Country:US
Mailing Address - Phone:217-245-4640
Mailing Address - Fax:217-245-4642
Practice Address - Street 1:901 W MORTON AVE
Practice Address - Street 2:SUITE 16A
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-3146
Practice Address - Country:US
Practice Address - Phone:217-245-4640
Practice Address - Fax:217-245-4642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Not Answered225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
06932016OtherBCBS GROUP NUMBER