Provider Demographics
NPI:1457499774
Name:PHYSIASERVPC
Entity Type:Organization
Organization Name:PHYSIASERVPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:ANIOLOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-370-3806
Mailing Address - Street 1:851 WHITE BIRCH LN
Mailing Address - Street 2:
Mailing Address - City:LAKE ZURICH
Mailing Address - State:IL
Mailing Address - Zip Code:60047-2663
Mailing Address - Country:US
Mailing Address - Phone:847-540-6756
Mailing Address - Fax:
Practice Address - Street 1:851 WHITE BIRCH LN
Practice Address - Street 2:
Practice Address - City:LAKE ZURICH
Practice Address - State:IL
Practice Address - Zip Code:60047-2663
Practice Address - Country:US
Practice Address - Phone:847-540-6756
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL200306Medicare ID - Type Unspecified
IL200305Medicare ID - Type Unspecified