Healthcare Provider Details

I. General information

NPI: 1871931840
Provider Name (Legal Business Name): KRS SPORTS MEDICINE AND REHABILITATION, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2013
Last Update Date: 11/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1749 N WELLS ST
CHICAGO IL
60614-5877
US

IV. Provider business mailing address

237 S WALNUT ST
GLENWOOD IL
60425-1880
US

V. Phone/Fax

Practice location:
  • Phone: 312-440-9646
  • Fax:
Mailing address:
  • Phone: 708-228-6689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number036.123210
License Number StateIL

VIII. Authorized Official

Name: KAMI REBECCA STRONG
Title or Position: PRESIDENT
Credential: M.D.
Phone: 708-228-6689