MEDICARE: SPINE REHABILITATION AND PAIN CLINIC

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	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1639514854
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPINE REHABILITATION AND PAIN CLINIC

Provider Business Mailing Address
First Line	:	2190 GLADSTONE CT
Second Line	:	SUITE B
City	:	GLENDALE HTS
State	:	IL
Zip	:	60139-1519
Country	:	US
Telephone Number	:	630-307-0200
Fax Number	:	312-377-1664

Provider Business Practice Location Address
First Line	:	2190 GLADSTONE CT
Second Line	:	SUITE B
City	:	GLENDALE HTS
State	:	IL
Zip	:	60139-1519
Country	:	US
Telephone Number	:	630-307-0200
Fax Number	:	312-377-1664

Authorized Official
Title or Position	:	VICE-PRESIDENT
Name	:	DR. PAUL RZESZUTEK
Credential	:	DN
Telephone Number	:	630-307-0200

Provider Enumeration Date	:	05/01/2013
Last Update Date	:	05/01/2013

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