Basic Information
| Provider Information | |||||||||
| NPI: | 1902059215 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEMORIAL HEALTH VENTURES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SPORTSCARE OF ILLINOIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3428 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627083428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005775368 | ||||||||
| FaxNumber: | 2177572021 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 CHATHAM RD | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627041533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178620444 | ||||||||
| FaxNumber: | 2175463584 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2008 | ||||||||
| LastUpdateDate: | 10/30/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ENGLAND | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, BUSINESS DEVELOPMEN | ||||||||
| AuthorizedOfficialTelephone: | 2177883851 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.