Provider Demographics
NPI:1235121393
Name:ADVANCED REHAB SPORTS MEDICINE
Entity type:Organization
Organization Name:ADVANCED REHAB SPORTS MEDICINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:OERTWIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-661-8823
Mailing Address - Street 1:PO BOX 5387
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61702-5387
Mailing Address - Country:US
Mailing Address - Phone:309-661-8823
Mailing Address - Fax:309-661-8801
Practice Address - Street 1:1201 E BROADWAY
Practice Address - Street 2:SUITE C
Practice Address - City:MONMOUTH
Practice Address - State:IL
Practice Address - Zip Code:61462-1994
Practice Address - Country:US
Practice Address - Phone:309-734-1103
Practice Address - Fax:309-734-2013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-16
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X, 225X00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL146672Medicare ID - Type Unspecified