Healthcare Provider Details

I. General information

NPI: 1336450386
Provider Name (Legal Business Name): FAMILY PHYSICAL MEDICINE CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2010
Last Update Date: 07/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2182 GLADSTONE CT SUITE B
GLENDALE HEIGHTS IL
60139-1517
US

IV. Provider business mailing address

281 E WRIGHTWOOD AVE
GLENDALE HEIGHTS IL
60139-2626
US

V. Phone/Fax

Practice location:
  • Phone: 708-991-9002
  • Fax: 708-991-9003
Mailing address:
  • Phone: 708-991-9002
  • Fax: 708-991-9003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172P00000X
TaxonomyNaprapath
License Number181000337
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070013531
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036114338
License Number StateIL

VIII. Authorized Official

Name: DR. KALLAHUR RAHAMAN
Title or Position: OWNER
Credential: DN
Phone: 630-863-5707