Provider Demographics
NPI:1598763864
Name:DYNACARE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:DYNACARE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:PETRICCA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:847-390-7666
Mailing Address - Street 1:116 S HI LUSI AVE
Mailing Address - Street 2:
Mailing Address - City:MT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-3025
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1455 E GOLF RD
Practice Address - Street 2:SUITE 110
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-1250
Practice Address - Country:US
Practice Address - Phone:847-390-7666
Practice Address - Fax:847-390-9345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL166=33438OtherBCBS
ILP11375Medicare UPIN
IL166=33438OtherBCBS