Healthcare Provider Details

I. General information

NPI: 1699557447
Provider Name (Legal Business Name): GENESIS PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2023
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 FOXFIELD RD STE 102
ST CHARLES IL
60174-5799
US

IV. Provider business mailing address

2900 FOXFIELD RD STE 102
ST CHARLES IL
60174-5799
US

V. Phone/Fax

Practice location:
  • Phone: 630-377-1188
  • Fax: 630-377-7360
Mailing address:
  • Phone: 630-377-1188
  • Fax: 630-377-7360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. ANDREW SHADID
Title or Position: CEO
Credential:
Phone: 630-377-1188