Provider Demographics
NPI:1407853393
Name:ADDISON PHYSICAL MEDICINE AND REHABILITATION CENTER LTD.
Entity Type:Organization
Organization Name:ADDISON PHYSICAL MEDICINE AND REHABILITATION CENTER LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:KRYS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:630-766-1552
Mailing Address - Street 1:199 S. ADDISON RD.
Mailing Address - Street 2:SUITE #106
Mailing Address - City:WOOD DALE
Mailing Address - State:IL
Mailing Address - Zip Code:60191-1534
Mailing Address - Country:US
Mailing Address - Phone:630-766-1552
Mailing Address - Fax:630-766-4220
Practice Address - Street 1:199 S. ADDISON RD.
Practice Address - Street 2:SUITE #106
Practice Address - City:WOOD DALE
Practice Address - State:IL
Practice Address - Zip Code:60191-1534
Practice Address - Country:US
Practice Address - Phone:630-766-1552
Practice Address - Fax:630-766-4220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X, 225100000X
IL038008124111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02222753OtherBC
IL02222753OtherBCBSIL
IL02222753OtherBCBSIL