Provider Demographics
NPI:1679778435
Name:ORTHOPEDIC REHAB SPECIALISTS OF DIXON, LLC
Entity type:Organization
Organization Name:ORTHOPEDIC REHAB SPECIALISTS OF DIXON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:K
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT, OMT
Authorized Official - Phone:815-227-1700
Mailing Address - Street 1:2662 MCFARLAND RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-6806
Mailing Address - Country:US
Mailing Address - Phone:815-284-1700
Mailing Address - Fax:815-284-1704
Practice Address - Street 1:201 LINCOLN STATUE DR
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-2000
Practice Address - Country:US
Practice Address - Phone:815-284-1700
Practice Address - Fax:815-284-1704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL215338Medicare PIN