Provider Demographics
NPI:1679526636
Name:LIBERTY PHYSICAL THERAPY AND REHABILITATION PC
Entity type:Organization
Organization Name:LIBERTY PHYSICAL THERAPY AND REHABILITATION PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KHALED
Authorized Official - Middle Name:
Authorized Official - Last Name:RASHAD
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPY
Authorized Official - Phone:708-334-9365
Mailing Address - Street 1:6526 S PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-5136
Mailing Address - Country:US
Mailing Address - Phone:773-585-9460
Mailing Address - Fax:773-585-7030
Practice Address - Street 1:6526 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-5136
Practice Address - Country:US
Practice Address - Phone:773-585-9460
Practice Address - Fax:773-585-7030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL325886294001Medicaid
IL212899Medicare PIN
IL325886294001Medicaid