Provider Demographics
NPI:1265474555
Name:HR PHYSICAL THERAPY , SPORTS & INDUSTRIAL REHABILITATION PC
Entity Type:Organization
Organization Name:HR PHYSICAL THERAPY , SPORTS & INDUSTRIAL REHABILITATION PC
Other - Org Name:HEARTLAND REHABILITATION
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROACH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:618-993-4024
Mailing Address - Street 1:3308 LOGAN DR
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-3759
Mailing Address - Country:US
Mailing Address - Phone:618-993-4024
Mailing Address - Fax:618-993-1570
Practice Address - Street 1:3308 LOGAN DR
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3759
Practice Address - Country:US
Practice Address - Phone:618-993-4024
Practice Address - Fax:618-993-1570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0700047172251X0800X
IL0700075952251X0800X
IL0700142662251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3467499841001Medicaid
IL344647789001Medicaid
IL484800286001Medicaid
ILK34547Medicare PIN
IL484800286001Medicaid
IL344647789001Medicaid