Provider Demographics
NPI:1306946777
Name:GATEWAY REHABILITATION TAYLORVILLE LLC
Entity type:Organization
Organization Name:GATEWAY REHABILITATION TAYLORVILLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:HAWKINS
Authorized Official - Suffix:
Authorized Official - Credentials:LPT
Authorized Official - Phone:618-258-9093
Mailing Address - Street 1:935 E AIRLINE DR
Mailing Address - Street 2:
Mailing Address - City:EAST ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62024
Mailing Address - Country:US
Mailing Address - Phone:618-258-9093
Mailing Address - Fax:618-258-9097
Practice Address - Street 1:301-305 S WEBSTER
Practice Address - Street 2:
Practice Address - City:TAYLORVILLE
Practice Address - State:IL
Practice Address - Zip Code:62568
Practice Address - Country:US
Practice Address - Phone:618-258-9093
Practice Address - Fax:618-258-9097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214311Medicare PIN