Provider Demographics
NPI:1649402629
Name:BATSON PEDIATRIC PHYSICAL THERAPY AND SPORT REHABILITATION
Entity Type:Organization
Organization Name:BATSON PEDIATRIC PHYSICAL THERAPY AND SPORT REHABILITATION
Other - Org Name:NICHOLAS A. BATSON
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:AVELLINO
Authorized Official - Last Name:BATSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:847-254-1708
Mailing Address - Street 1:25753 W IVANHOE RD
Mailing Address - Street 2:
Mailing Address - City:WAUCONDA
Mailing Address - State:IL
Mailing Address - Zip Code:60084-2366
Mailing Address - Country:US
Mailing Address - Phone:847-254-1708
Mailing Address - Fax:847-487-2285
Practice Address - Street 1:25753 W IVANHOE RD
Practice Address - Street 2:
Practice Address - City:WAUCONDA
Practice Address - State:IL
Practice Address - Zip Code:60084-2366
Practice Address - Country:US
Practice Address - Phone:847-254-1708
Practice Address - Fax:847-487-0759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-10
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213000023246Z00000X
IL070011615246Z00000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherGroup - Multi-Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL110624814001Medicaid
IL110624814001Medicaid