Healthcare Provider Details

I. General information

NPI: 1235251026
Provider Name (Legal Business Name): BUFFALO GROVE PHYSICAL THERAPY AND SPORTS REHABILITATION PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 07/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 EAST LAKE COOK RD SUITE 209
BUFFALO GROVE IL
60089
US

IV. Provider business mailing address

125 EAST LAKE COOK RD SUITE 209
BUFFALO GROVE IL
60089
US

V. Phone/Fax

Practice location:
  • Phone: 847-520-3382
  • Fax: 847-520-3404
Mailing address:
  • Phone: 847-520-3382
  • Fax: 847-520-3404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070013042
License Number StateIL

VIII. Authorized Official

Name: MR. GOPAL TERALANDUR RAGHUNATH
Title or Position: OWNER
Credential: MSPT DPT CSPT
Phone: 847-564-1349