Provider Demographics
NPI:1902210008
Name:SOUTH CHICAGO PHYSICIAL MEDICINE
Entity Type:Organization
Organization Name:SOUTH CHICAGO PHYSICIAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:P
Authorized Official - Last Name:TOULIOS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:773-350-1763
Mailing Address - Street 1:11003 S KEDZIE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-2221
Mailing Address - Country:US
Mailing Address - Phone:773-350-1763
Mailing Address - Fax:
Practice Address - Street 1:11003 S KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60655-2221
Practice Address - Country:US
Practice Address - Phone:773-350-1763
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-17
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400120638OtherPTAN/MEDICARE