Provider Demographics
NPI:1568729986
Name:TRICARE MEDICAL GROUP OF MIDWEST INC.
Entity Type:Organization
Organization Name:TRICARE MEDICAL GROUP OF MIDWEST INC.
Other - Org Name:FOX VALLEY PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SIFATUR
Authorized Official - Middle Name:R
Authorized Official - Last Name:SAYEED
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-499-1900
Mailing Address - Street 1:3535 EAST NEW YORK STREET
Mailing Address - Street 2:SUITE 119
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-4427
Mailing Address - Country:US
Mailing Address - Phone:630-499-1900
Mailing Address - Fax:630-499-1903
Practice Address - Street 1:3535 EAST NEW YORK STREET
Practice Address - Street 2:SUITE 119
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-4427
Practice Address - Country:US
Practice Address - Phone:630-499-1900
Practice Address - Fax:630-499-1903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-23
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036094039Medicaid