Provider Demographics
NPI:1467661215
Name:ELGIN PHYSICAL HEALTH CENTER
Entity Type:Organization
Organization Name:ELGIN PHYSICAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:GIBBONS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-697-2211
Mailing Address - Street 1:1510 LARKIN AVE
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-5190
Mailing Address - Country:US
Mailing Address - Phone:847-697-2211
Mailing Address - Fax:847-697-2215
Practice Address - Street 1:1510 LARKIN AVE
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-5190
Practice Address - Country:US
Practice Address - Phone:847-697-2211
Practice Address - Fax:847-697-2215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X, 111N00000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0004515239OtherBC BS PROVIDER NUMBER