Healthcare Provider Details

I. General information

NPI: 1851776439
Provider Name (Legal Business Name): ROSELLE PHYSICAL MEDICINE GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2015
Last Update Date: 07/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 E IRVING PARK RD
ROSELLE IL
60172-2050
US

IV. Provider business mailing address

50 E IRVING PARK RD
ROSELLE IL
60172-2050
US

V. Phone/Fax

Practice location:
  • Phone: 630-295-8851
  • Fax: 630-295-8852
Mailing address:
  • Phone: 630-295-8851
  • Fax: 630-295-8852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. TARIQ AHMED
Title or Position: PRESIDENT
Credential: DC
Phone: 630-295-8851