Provider Demographics
NPI:1245280213
Name:VICTORY AMBULATORY SERVICES
Entity type:Organization
Organization Name:VICTORY AMBULATORY SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:J
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-360-3000
Mailing Address - Street 1:1050 RED OAK LN
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60046-4998
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1050 RED OAK LN
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:IL
Practice Address - Zip Code:60046-4998
Practice Address - Country:US
Practice Address - Phone:847-356-4700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL7002322261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210257Medicare ID - Type UnspecifiedMEDICARE ID