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General NPI Number Information
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NPI Number | 1063632917
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Entity Type | Organization
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Legal Business Name | PROFESSIONAL HEALTH SPORT, INC.
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Dates
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Enumeration Date | 04/25/2007
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Last Update Date | 10/01/2007
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Provider Practice Location Address
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Address Line | 6288 N CICERO AVE
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City | CHICAGO
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State | IL
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Zip | 60646-4918
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Country | US
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Telephone | 773-205-1418
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Fax |
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Provider Business Mailing Address
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Address Line | 6288 N CICERO AVE
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City | CHICAGO
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State | IL
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Zip | 60646-4918
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Country | US
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Telephone | 773-205-1418
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. JOHN H DEHELEAN
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Credential |
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Telephone | 773-205-1418
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208VP0014X
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Taxonomy Name | Interventional Pain Medicine Physician
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License Number |
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State | IL
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