Healthcare Provider Details

I. General information

NPI: 1871640565
Provider Name (Legal Business Name): SPORTS AND ORTHO P.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 12/24/2023
Certification Date: 12/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 W 31ST ST
CHICAGO IL
60616-3116
US

IV. Provider business mailing address

412 W 31ST ST
CHICAGO IL
60616-3116
US

V. Phone/Fax

Practice location:
  • Phone: 312-225-3119
  • Fax: 312-225-3219
Mailing address:
  • Phone: 312-225-3119
  • Fax: 312-225-3219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DAHLIA FAHMY
Title or Position: PRESIDENT/OWNER
Credential: PT
Phone: 312-375-5354