Provider Demographics
NPI:1700953924
Name:PREMIER REHAB, LTD
Entity Type:Organization
Organization Name:PREMIER REHAB, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BERTELSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-236-3738
Mailing Address - Street 1:4460 N ILLINOIS ST
Mailing Address - Street 2:#5
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-1899
Mailing Address - Country:US
Mailing Address - Phone:618-236-3738
Mailing Address - Fax:618-257-3291
Practice Address - Street 1:4460 N ILLINOIS ST
Practice Address - Street 2:#5
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-1899
Practice Address - Country:US
Practice Address - Phone:618-236-3738
Practice Address - Fax:618-257-3291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212024Medicare PIN