MEDICARE: PROREHAB PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center
2	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1053820175
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROREHAB PC

Provider Business Mailing Address
First Line	:	625 ENTERPRISE DR
Second Line	:
City	:	OAK BROOK
State	:	IL
Zip	:	60523-8813
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11525 OLDE CABIN RD STE 1
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63141-7146
Country	:	US
Telephone Number	:	636-239-9979
Fax Number	:	636-239-5442

Authorized Official
Title or Position	:	VP OF BILLING OPERATIONS
Name	:	GERI COOK
Credential	:
Telephone Number	:	630-575-1940

Provider Enumeration Date	:	09/20/2017
Last Update Date	:	09/20/2017

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