Provider Demographics
NPI:1134239346
Name:COMMUNITY PROFESSIONAL REHAB
Entity type:Organization
Organization Name:COMMUNITY PROFESSIONAL REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ASHRAG
Authorized Official - Middle Name:
Authorized Official - Last Name:TEBRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-374-7800
Mailing Address - Street 1:10559 S TORRENCE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-6154
Mailing Address - Country:US
Mailing Address - Phone:773-374-7800
Mailing Address - Fax:773-374-9091
Practice Address - Street 1:10559 S TORRENCE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-6154
Practice Address - Country:US
Practice Address - Phone:773-374-7800
Practice Address - Fax:773-374-9091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL322888333001225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL322888333001Medicaid
IL207513Medicare ID - Type UnspecifiedMEDICARE PROVIDER #