Provider Demographics
NPI:1063594794
Name:SBPT INC
Entity type:Organization
Organization Name:SBPT INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:WALLNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-768-9240
Mailing Address - Street 1:1480 RENAISSANCE DRIVE
Mailing Address - Street 2:STE 304
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068
Mailing Address - Country:US
Mailing Address - Phone:847-768-9240
Mailing Address - Fax:847-768-9304
Practice Address - Street 1:1480 RENAISSANCE DRIVE
Practice Address - Street 2:STE 304
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068
Practice Address - Country:US
Practice Address - Phone:847-768-9240
Practice Address - Fax:847-768-9304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL322924361001Medicaid
IL144519Medicare ID - Type Unspecified