Provider Demographics
NPI:1922125541
Name:PHYSICAL THERAPY AND SPORTS INJURY REHABILITATION
Entity Type:Organization
Organization Name:PHYSICAL THERAPY AND SPORTS INJURY REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:WALTER
Authorized Official - Last Name:KAUMEYER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:708-335-1415
Mailing Address - Street 1:2 RIVER PL
Mailing Address - Street 2:SUITE B
Mailing Address - City:LANSING
Mailing Address - State:IL
Mailing Address - Zip Code:60438-6028
Mailing Address - Country:US
Mailing Address - Phone:708-895-9860
Mailing Address - Fax:708-895-9866
Practice Address - Street 1:2 RIVER PL
Practice Address - Street 2:SUITE B
Practice Address - City:LANSING
Practice Address - State:IL
Practice Address - Zip Code:60438-6028
Practice Address - Country:US
Practice Address - Phone:708-895-9860
Practice Address - Fax:708-895-9866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Not Answered2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL738280Medicare ID - Type Unspecified