Provider Demographics
NPI:1174648737
Name:SO ILLINOIS NEUROLOGY & REHAB
Entity Type:Organization
Organization Name:SO ILLINOIS NEUROLOGY & REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PRITAM
Authorized Official - Middle Name:S
Authorized Official - Last Name:SAHNI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-242-6465
Mailing Address - Street 1:1702 BROADWAY ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2930
Mailing Address - Country:US
Mailing Address - Phone:618-242-6465
Mailing Address - Fax:618-242-6463
Practice Address - Street 1:1702 BROADWAY ST
Practice Address - Street 2:SUITE C
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2930
Practice Address - Country:US
Practice Address - Phone:618-242-6465
Practice Address - Fax:618-242-6463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-051778174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty