Provider Demographics
NPI:1184676835
Name:CENTERIMT CHICAGO IL PC
Entity Type:Organization
Organization Name:CENTERIMT CHICAGO IL PC
Other - Org Name:CENTER IMT CHICAGO
Other - Org Type:Other Name
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MEEJUNG
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MPT, IMT, C
Authorized Official - Phone:630-279-0032
Mailing Address - Street 1:180 W. PARK AVE.
Mailing Address - Street 2:STE. 250
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-3357
Mailing Address - Country:US
Mailing Address - Phone:630-279-0032
Mailing Address - Fax:630-279-1833
Practice Address - Street 1:180 W. PARK AVE.
Practice Address - Street 2:STE. 250
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-3357
Practice Address - Country:US
Practice Address - Phone:630-279-0032
Practice Address - Fax:630-279-1833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2009-03-30
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
IL210661Medicare PIN
IL212229Medicare PIN