Provider Demographics
NPI:1558493064
Name:AW PHYSICAL REHAB, LTD.
Entity Type:Organization
Organization Name:AW PHYSICAL REHAB, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-551-7022
Mailing Address - Street 1:1069 W ARGYLE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-3707
Mailing Address - Country:US
Mailing Address - Phone:773-728-7022
Mailing Address - Fax:773-989-9180
Practice Address - Street 1:1069 W ARGYLE ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-3707
Practice Address - Country:US
Practice Address - Phone:773-728-7022
Practice Address - Fax:773-989-9180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211756Medicare ID - Type UnspecifiedMEDICARE GROUP PROVIDER #