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General NPI Number Information
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NPI Number | 1235251026
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Entity Type | Organization
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Legal Business Name | BUFFALO GROVE PHYSICAL THERAPY AND SPORTS REHABILITATION PC
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Dates
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Enumeration Date | 04/04/2007
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Last Update Date | 07/15/2008
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Provider Practice Location Address
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Address Line | 125 EAST LAKE COOK RD SUITE 209
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City | BUFFALO GROVE
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State | IL
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Zip | 60089
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Country | US
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Telephone | 847-520-3382
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Fax | 847-520-3404
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Provider Business Mailing Address
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Address Line | 125 EAST LAKE COOK RD SUITE 209
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City | BUFFALO GROVE
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State | IL
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Zip | 60089
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Country | US
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Telephone | 847-520-3382
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Fax | 847-520-3404
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Authorized Official
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Title or Position | OWNER
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Name | MR. GOPAL TERALANDUR RAGHUNATH
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Credential | MSPT DPT CSPT
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Telephone | 847-564-1349
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 070013042
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License Number State | IL
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