Healthcare Provider Details

I. General information

NPI: 1235121393
Provider Name (Legal Business Name): ADVANCED REHAB SPORTS MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 11/03/2022
Certification Date: 11/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 E BROADWAY SUITE C
MONMOUTH IL
61462-1994
US

IV. Provider business mailing address

PO BOX 5387
BLOOMINGTON IL
61702-5387
US

V. Phone/Fax

Practice location:
  • Phone: 309-734-1103
  • Fax: 309-734-2013
Mailing address:
  • Phone: 309-661-8823
  • Fax: 309-661-8801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateIL

VIII. Authorized Official

Name: MARK STEVEN OERTWIG
Title or Position: DIRECTOR OF FINANCE
Credential:
Phone: 309-661-8823