Provider Demographics
NPI:1790886307
Name:PHYSICAL THERAPY RENAISSANCE LTD
Entity Type:Organization
Organization Name:PHYSICAL THERAPY RENAISSANCE LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF PHYSICAL THERAPY
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:FLAGE
Authorized Official - Last Name:HOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, MTC, CFC, C
Authorized Official - Phone:312-986-9833
Mailing Address - Street 1:25 E WASHINGTON ST STE 1318
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-1708
Mailing Address - Country:US
Mailing Address - Phone:312-986-9833
Mailing Address - Fax:312-962-8855
Practice Address - Street 1:25 E WASHINGTON ST STE 1310
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-1863
Practice Address - Country:US
Practice Address - Phone:312-986-9833
Practice Address - Fax:773-665-9947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012508225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070012508Medicaid
IL02232891OtherBCBS
IL070012508Medicaid