Provider Demographics
NPI:1275651242
Name:ILLINOIS SPINAL & SPORTS REHABILITATION SC
Entity Type:Organization
Organization Name:ILLINOIS SPINAL & SPORTS REHABILITATION SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:J
Authorized Official - Last Name:LUKOSUS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:630-904-9700
Mailing Address - Street 1:4015 PLAINFIELD NAPERVILLE RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-4136
Mailing Address - Country:US
Mailing Address - Phone:630-904-9700
Mailing Address - Fax:630-904-9713
Practice Address - Street 1:4015 PLAINFIELD NAPERVILLE RD
Practice Address - Street 2:SUITE 105
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564-4136
Practice Address - Country:US
Practice Address - Phone:630-904-9700
Practice Address - Fax:630-904-9713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN038008240111N00000X
IL70015459225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1992774277OtherINDIVIDUAL NPI
IL9932170OtherBLUE CROSS BLUE SHIELD
IL1427196583OtherINDIVIDUAL NPI
IL7553267OtherAETNA ID
IL209997Medicare ID - Type Unspecified
ILU84782Medicare UPIN