Healthcare Provider Details

I. General information

NPI: 1326884743
Provider Name (Legal Business Name): SNF PHYSIATRY SERVICES IL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2024
Last Update Date: 08/28/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 E ERIE ST
CHICAGO IL
60611-2740
US

IV. Provider business mailing address

8420 N KNOXVILLE AVE SUITE C #1059
PEORIA IL
61615
US

V. Phone/Fax

Practice location:
  • Phone: 732-813-0799
  • Fax:
Mailing address:
  • Phone: 203-217-9500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: MOSHE NATH
Title or Position: CEO
Credential:
Phone: 732-813-0799