Provider Demographics
NPI:1336127117
Name:PREMIER PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:PREMIER PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING TEAM LEADER
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTAL
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:LEONARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-920-4670
Mailing Address - Street 1:1000 BURR RIDGE PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-0845
Mailing Address - Country:US
Mailing Address - Phone:630-920-4670
Mailing Address - Fax:630-920-4687
Practice Address - Street 1:3900 W 95TH ST
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805
Practice Address - Country:US
Practice Address - Phone:630-920-4670
Practice Address - Fax:630-920-4687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-03
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070007675225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL594253799001Medicaid
IL621460Medicare ID - Type UnspecifiedCOOK COUNTY
IL205070Medicare ID - Type UnspecifiedDUPAGE COUNTY