=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003036344
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYSICAL THERAPY CLINIC OF CHICAGO, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6135 W BELMONT AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60634-5165
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-237-7827
-----------------------------------------------------
Fax | 773-237-7826
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6135 W BELMONT AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60634-5165
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-237-7827
-----------------------------------------------------
Fax | 773-237-7826
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JAROSLAW PRUS
-----------------------------------------------------
Credential | P.T.
-----------------------------------------------------
Telephone | 773-237-7827
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------