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General NPI Number Information
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NPI Number | 1700482114
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Entity Type | Organization
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Legal Business Name | PRAIRIE STATE REHAB, LLC
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Dates
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Enumeration Date | 12/10/2020
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Last Update Date | 12/10/2020
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Provider Practice Location Address
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Address Line | 711 S DEARBORN ST UNIT 705
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City | CHICAGO
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State | IL
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Zip | 60605-3820
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Country | US
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Telephone | 708-966-9283
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Fax | 708-258-1632
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Provider Business Mailing Address
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Address Line | 711 S DEARBORN ST UNIT 705
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City | CHICAGO
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State | IL
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Zip | 60605-3820
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Country | US
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Telephone | 708-966-9283
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Fax | 708-258-1632
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Authorized Official
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Title or Position | CEO
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Name | DR. JASON FREEMAN
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Credential | DO
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Telephone | 708-275-4087
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number |
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License Number State |
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