Healthcare Provider Details

I. General information

NPI: 1083655336
Provider Name (Legal Business Name): JESSE BROWN VA MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 S DAMEN
CHICAGO IL
60612
US

IV. Provider business mailing address

476 ALLES ST
DES PLAINES IL
60016-7871
US

V. Phone/Fax

Practice location:
  • Phone: 312-569-6397
  • Fax:
Mailing address:
  • Phone: 708-539-8119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateIL

VIII. Authorized Official

Name: MRS. SUBHADRA S VUNDAVILLI
Title or Position: PHYSICAL THERAPIST
Credential: PT
Phone: 312-569-6397