Provider Demographics
NPI:1710150453
Name:COVENANT PHYSIATRY,SC
Entity Type:Organization
Organization Name:COVENANT PHYSIATRY,SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDHYA
Authorized Official - Middle Name:R
Authorized Official - Last Name:MEESALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-852-6478
Mailing Address - Street 1:PO BOX 967
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-0967
Mailing Address - Country:US
Mailing Address - Phone:708-532-6029
Mailing Address - Fax:708-532-6095
Practice Address - Street 1:1590 W ALGONQUIN RD
Practice Address - Street 2:SUITE 167
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60192-1575
Practice Address - Country:US
Practice Address - Phone:847-852-6478
Practice Address - Fax:847-382-1646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036110423208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001638924OtherBS#
IL036110423Medicaid
IL216987Medicare PIN
IL036110423Medicaid
ILIL4673Medicare PIN
IL216456Medicare PIN