Provider Demographics
NPI:1902969413
Name:SOMA REHAB INC
Entity type:Organization
Organization Name:SOMA REHAB INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ARA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:BOYLAND
Authorized Official - Suffix:
Authorized Official - Credentials:BS PHYSICAL THERAPY
Authorized Official - Phone:773-521-5300
Mailing Address - Street 1:3004 SOUTH PULASKI ROAD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623
Mailing Address - Country:US
Mailing Address - Phone:773-521-5300
Mailing Address - Fax:773-521-5305
Practice Address - Street 1:3004 SOUTH PULASKI ROAD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623
Practice Address - Country:US
Practice Address - Phone:773-521-5300
Practice Address - Fax:773-521-5305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL593354121001Medicaid
IL=========OtherIRS TAX ID
IL=========OtherIRS TAX ID