Provider Demographics
NPI:1164680492
Name:ADVANTAGE PHYSICAL THERAPY ASSOCIATES, SC
Entity type:Organization
Organization Name:ADVANTAGE PHYSICAL THERAPY ASSOCIATES, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:DALLAS
Authorized Official - Suffix:
Authorized Official - Credentials:LPT
Authorized Official - Phone:630-792-9790
Mailing Address - Street 1:PO BOX 72180
Mailing Address - Street 2:
Mailing Address - City:ROSELLE
Mailing Address - State:IL
Mailing Address - Zip Code:60172-0180
Mailing Address - Country:US
Mailing Address - Phone:630-792-9790
Mailing Address - Fax:630-792-9794
Practice Address - Street 1:6234 MAIN ST
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60516-1908
Practice Address - Country:US
Practice Address - Phone:630-960-9914
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-002882225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1164680492OtherBLUE CROSS BLUE SHIELD
ILIL1443Medicare PIN