Provider Demographics
NPI:1063632917
Name:PROFESSIONAL HEALTH SPORT, INC.
Entity type:Organization
Organization Name:PROFESSIONAL HEALTH SPORT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:H
Authorized Official - Last Name:DEHELEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-205-1418
Mailing Address - Street 1:6288 N CICERO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-4918
Mailing Address - Country:US
Mailing Address - Phone:773-205-1418
Mailing Address - Fax:
Practice Address - Street 1:6288 N CICERO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-4918
Practice Address - Country:US
Practice Address - Phone:773-205-1418
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208VP0014X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL207367Medicare ID - Type UnspecifiedPROVIDER GROUP NUMBER