Provider Demographics
NPI:1467467142
Name:BACK CENTER OF CHICAGO
Entity Type:Organization
Organization Name:BACK CENTER OF CHICAGO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-867-7090
Mailing Address - Street 1:1731 N MARCEY ST
Mailing Address - Street 2:SUITE 530
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-5373
Mailing Address - Country:US
Mailing Address - Phone:312-867-7090
Mailing Address - Fax:312-867-7081
Practice Address - Street 1:1731 N MARCEY ST
Practice Address - Street 2:SUITE 530
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-5373
Practice Address - Country:US
Practice Address - Phone:312-867-7090
Practice Address - Fax:312-867-7081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-037992174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty