Provider Demographics
NPI:1700839701
Name:MID AMERICA REHABILITATION CONSULTANTS INC
Entity Type:Organization
Organization Name:MID AMERICA REHABILITATION CONSULTANTS INC
Other - Org Name:MID AMERICA MEDICAL & DIAGNOSTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEKSEY
Authorized Official - Middle Name:
Authorized Official - Last Name:POLYAKOV
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-731-6727
Mailing Address - Street 1:2640 SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:ZION
Mailing Address - State:IL
Mailing Address - Zip Code:60099-2615
Mailing Address - Country:US
Mailing Address - Phone:847-731-6727
Mailing Address - Fax:847-731-6739
Practice Address - Street 1:2640 SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:ZION
Practice Address - State:IL
Practice Address - Zip Code:60099-2615
Practice Address - Country:US
Practice Address - Phone:847-731-6727
Practice Address - Fax:847-731-6739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042618331111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU97620Medicare UPIN
IL207653Medicare PIN
IL211403Medicare PIN