Provider Demographics
NPI:1740256155
Name:MIDWAY NEUROLOGICAL AND REHABILITATION CENTER LLC
Entity type:Organization
Organization Name:MIDWAY NEUROLOGICAL AND REHABILITATION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MOISHE
Authorized Official - Middle Name:
Authorized Official - Last Name:GUBIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-898-3056
Mailing Address - Street 1:8540 S HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60455-1778
Mailing Address - Country:US
Mailing Address - Phone:708-598-2605
Mailing Address - Fax:708-598-5671
Practice Address - Street 1:8540 S HARLEM AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEVIEW
Practice Address - State:IL
Practice Address - Zip Code:60455-1778
Practice Address - Country:US
Practice Address - Phone:708-598-2605
Practice Address - Fax:708-598-5671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-24
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL000047175314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========801Medicaid
IL=========801Medicaid
IL=========001Medicaid