Basic Information
| Provider Information | |||||||||
| NPI: | 1710919063 | ||||||||
| 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 | ||||||||
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| Practice Location | |||||||||
| Address1: | 124 MYRON ST | ||||||||
| Address2: | |||||||||
| City: | WEST SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010891420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135269969 | ||||||||
| FaxNumber: | 4135269960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 06/08/2017 | ||||||||
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| AuthorizedOfficialLastName: | MCGIVERN | ||||||||
| AuthorizedOfficialFirstName: | LYNN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF COMPLIANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6302962223 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251H1200X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Hand | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225XH1200X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 03527 | 01 | MA | BMC GROUP ELM | OTHER | 043527 | 01 | MA | CT CARE | OTHER | 103355100 | 01 | MA | DEPT. OF LABOR | OTHER | Y61264 | 01 | MA | BLUE CROSS | OTHER | 4510980001 | 01 | MA | DME | OTHER | 690675 | 01 | MA | TUFT | OTHER | 28117 | 01 | MA | HNE | OTHER | 35264 | 01 | MA | BMC-GROUP-DENDLOW | OTHER | 35265 | 01 | MA | BMC GROUP ELM | OTHER | 64-04290 | 01 | MA | UNITED | OTHER | 972730 | 01 | MA | NETWORK HEALTH | OTHER | AA49027 | 01 | MA | HARVARD PILGRIM | OTHER | OG0011 | 01 | MA | BLUE CROSS OT | OTHER | 9715568 | 05 | MA | MEDICAID |