Provider Demographics
NPI:1699557447
Name:GENESIS PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:GENESIS PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:SHADID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-377-1188
Mailing Address - Street 1:2900 FOXFIELD RD STE 102
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-5799
Mailing Address - Country:US
Mailing Address - Phone:630-377-1188
Mailing Address - Fax:630-377-7360
Practice Address - Street 1:2900 FOXFIELD RD STE 102
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-5799
Practice Address - Country:US
Practice Address - Phone:630-377-1188
Practice Address - Fax:630-377-7360
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENESIS ORTHOPEDICS & SPORTS MEDICINE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-10-17
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine