Basic Information
| Provider Information | |||||||||
| NPI: | 1447445523 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PERFORMANCE REHABILITATION OF WESTERN NEW ENGLAND LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ATI PHYSICAL THERAPY OF WESTERN MASSACHUSETTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
| FaxNumber: | 6307599510 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 BIRNIE AVE | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137811054 | ||||||||
| FaxNumber: | 4134390026 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2007 | ||||||||
| LastUpdateDate: | 06/08/2017 | ||||||||
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| AuthorizedOfficialLastName: | MCGIVERN | ||||||||
| AuthorizedOfficialFirstName: | LYNN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF COMPLIANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6302962223 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | MA | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251H1200X | MA | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Hand | 225XH1200X | MA | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand | 225X00000X | MA | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 972730 | 01 | MA | NETWORK HEALTH | OTHER | 64-04290 | 01 | MA | UNITED | OTHER | OG0011 | 01 | MA | BLUE SHIELD OT | OTHER | 9715668 | 05 | MA | MEDICAID | 043527 | 01 | MA | CT CARE | OTHER | 28117 | 01 | MA | HNE | OTHER | 000000035257 | 01 | MA | BOSTON MEDICAL CENTER | OTHER | 690675 | 01 | MA | TUFTS | OTHER | 103355100 | 01 | MA | DEPT OF LABOR | OTHER | Y61264 | 01 | MA | BLUE SHIEL PT | OTHER |