Provider Demographics
NPI:1104885136
Name:SELECT PHYSICAL THERAPY OF ILLINOIS LIMITED PARTNERSHIP
Entity type:Organization
Organization Name:SELECT PHYSICAL THERAPY OF ILLINOIS LIMITED PARTNERSHIP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:TARVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-972-1100
Mailing Address - Street 1:4714 GETTYSBURG RD
Mailing Address - Street 2:
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17055-4325
Mailing Address - Country:US
Mailing Address - Phone:717-972-1100
Mailing Address - Fax:717-975-9781
Practice Address - Street 1:820 E TERRA COTTA AVE
Practice Address - Street 2:STE 102
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014
Practice Address - Country:US
Practice Address - Phone:815-455-3262
Practice Address - Fax:815-455-2729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-20
Last Update Date:2010-09-01
Deactivation Date:2007-11-20
Deactivation Code:
Reactivation Date:2008-01-04
Provider Licenses
StateLicense IDTaxonomies
261QR0400X
IL261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL146666Medicare Oscar/Certification