Provider Demographics
NPI:1831368612
Name:NORTHERN REHABILITATION AND SPORTS MEDICINE ASSOCIATES
Entity type:Organization
Organization Name:NORTHERN REHABILITATION AND SPORTS MEDICINE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:L
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-756-8524
Mailing Address - Street 1:3266 RESOURCE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115
Mailing Address - Country:US
Mailing Address - Phone:815-756-8524
Mailing Address - Fax:815-756-1841
Practice Address - Street 1:540 E MAIN STREET
Practice Address - Street 2:SUITE 5
Practice Address - City:GENOA
Practice Address - State:IL
Practice Address - Zip Code:60135
Practice Address - Country:US
Practice Address - Phone:815-784-6417
Practice Address - Fax:815-784-3178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-26
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL544960Medicare UPIN