Provider Demographics
NPI:1104836105
Name:ADVANCE PHYSICAL THERAPY & SPORTS MEDICINE OF ADAMS COUNTY LLC
Entity Type:Organization
Organization Name:ADVANCE PHYSICAL THERAPY & SPORTS MEDICINE OF ADAMS COUNTY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:REIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-222-6800
Mailing Address - Street 1:160 PROGRESS RD STE 111
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-6630
Mailing Address - Country:US
Mailing Address - Phone:217-222-9300
Mailing Address - Fax:217-222-9400
Practice Address - Street 1:927 BROADWAY ST
Practice Address - Street 2:SUITE 100
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2719
Practice Address - Country:US
Practice Address - Phone:217-222-9300
Practice Address - Fax:217-222-9400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2024-01-23
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
IL211412Medicare PIN