Provider Demographics
NPI:1457844615
Name:JAIN, MAHENDRA KUMAR
Entity Type:Individual
Prefix:MR
First Name:MAHENDRA
Middle Name:KUMAR
Last Name:JAIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-1673
Mailing Address - Country:US
Mailing Address - Phone:779-696-7550
Mailing Address - Fax:
Practice Address - Street 1:2550 CHARLES ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-1673
Practice Address - Country:US
Practice Address - Phone:779-696-7550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-12
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.00392225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
J500-5514-5200OtherSECRETORY OF STATE,STATE OF OF IL