Healthcare Provider Details

I. General information

NPI: 1124326038
Provider Name (Legal Business Name): ATHLETIC EDGE PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2011
Last Update Date: 06/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1319 S MICHIGAN AVE
CHICAGO IL
60605-2601
US

IV. Provider business mailing address

1319 S MICHIGAN AVE
CHICAGO IL
60605-2601
US

V. Phone/Fax

Practice location:
  • Phone: 312-617-5949
  • Fax: 312-447-0036
Mailing address:
  • Phone: 312-617-5949
  • Fax: 312-447-0036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number070015130
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070015130
License Number StateIL

VIII. Authorized Official

Name: MR. DANIEL L GRAY
Title or Position: CEO
Credential:
Phone: 312-617-5949