Provider Demographics
NPI:1477546935
Name:PHYSICAL MEDICINE ASSOCIATES SC
Entity Type:Organization
Organization Name:PHYSICAL MEDICINE ASSOCIATES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OM
Authorized Official - Prefix:
Authorized Official - First Name:TARYN
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-450-2088
Mailing Address - Street 1:24W500 MAPLE AVE
Mailing Address - Street 2:#105
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-6055
Mailing Address - Country:US
Mailing Address - Phone:630-428-4300
Mailing Address - Fax:630-428-4305
Practice Address - Street 1:429 N KIRK RD STE 103
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-1667
Practice Address - Country:US
Practice Address - Phone:630-605-6323
Practice Address - Fax:630-428-4305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-30
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042617710111N00000X, 207Q00000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02232261OtherBCBS PROVIDER #
IL205571Medicare PIN