Provider Demographics
NPI:1326150624
Name:SPORTS PHYSICAL THERAPY & REHAB SPECIALISTS, S.C.
Entity Type:Organization
Organization Name:SPORTS PHYSICAL THERAPY & REHAB SPECIALISTS, S.C.
Other - Org Name:ATHLETICO PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JUANA
Authorized Official - Middle Name:L
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-575-1980
Mailing Address - Street 1:625 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8813
Mailing Address - Country:US
Mailing Address - Phone:630-575-1980
Mailing Address - Fax:630-928-5080
Practice Address - Street 1:3915 30TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1957
Practice Address - Country:US
Practice Address - Phone:262-657-0222
Practice Address - Fax:262-657-7190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000085940OtherMEDICARE
WI000086040OtherMEDICARE
IL4919795OtherBCBS OF IL
ILCG8674OtherRAILROAD MEDICARE NUMBER
WIWI2660OtherMEDICARE
WI40415400Medicaid
WICJ6927OtherRAILROAD MEDICARE NUMBER
IL4919795OtherBCBS OF IL
WI86040Medicare ID - Type UnspecifiedOT
ILCG8674OtherRAILROAD MEDICARE NUMBER
IL539320Medicare ID - Type Unspecified
WI0604410001Medicare NSC