Healthcare Provider Details

I. General information

NPI: 1063632917
Provider Name (Legal Business Name): PROFESSIONAL HEALTH SPORT, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 10/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6288 N CICERO AVE
CHICAGO IL
60646-4918
US

IV. Provider business mailing address

6288 N CICERO AVE
CHICAGO IL
60646-4918
US

V. Phone/Fax

Practice location:
  • Phone: 773-205-1418
  • Fax:
Mailing address:
  • Phone: 773-205-1418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: MR. JOHN H DEHELEAN
Title or Position: PRESIDENT
Credential:
Phone: 773-205-1418