Provider Demographics
NPI:1801839576
Name:PERFORMANCE PHYSICAL THERAPY OF PALOS PARK
Entity Type:Organization
Organization Name:PERFORMANCE PHYSICAL THERAPY OF PALOS PARK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:D
Authorized Official - Last Name:JUDGE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:219-979-2730
Mailing Address - Street 1:13125 S LA GRANGE RD
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-1162
Mailing Address - Country:US
Mailing Address - Phone:708-671-1971
Mailing Address - Fax:708-671-1973
Practice Address - Street 1:13125 S LA GRANGE RD
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-1162
Practice Address - Country:US
Practice Address - Phone:708-671-1971
Practice Address - Fax:708-671-1973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDF4225Medicare PIN
IL213966Medicare PIN