Basic Information
| Provider Information | |||||||||
| NPI: | 1013976927 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIDWEST ORTHOPAEDIC INSTITUTE P C | ||||||||
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| OtherOrganizationName: | MIDWEST ORTHOPAEDIC INSTITUTE SC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1952 ABERDEEN CT | ||||||||
| Address2: | |||||||||
| City: | SYCAMORE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601783175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157580000 | ||||||||
| FaxNumber: | 8157483014 | ||||||||
| Practice Location | |||||||||
| Address1: | 2111 MIDLANDS COURT | ||||||||
| Address2: | |||||||||
| City: | SYCAMORE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157580000 | ||||||||
| FaxNumber: | 8157580094 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2006 | ||||||||
| LastUpdateDate: | 08/29/2018 | ||||||||
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| AuthorizedOfficialLastName: | ROSS | ||||||||
| AuthorizedOfficialFirstName: | ASHLEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 8159912333 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RR0500X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 207T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery | 213EP1101X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Primary Podiatric Medicine | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 261QM2500X | 060010536 | IL | N | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty | 261QR0400X | 060010536 | IL | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation | 332B00000X | 060010536 | IN | N | Suppliers | Durable Medical Equipment & Medical Supplies | 332B00000X | 060010536 | IL | N | Suppliers | Durable Medical Equipment & Medical Supplies | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1915167 | 01 | IL | BLUE CROSS/BLUE SHIELD | OTHER | 041032 | 01 | IL | HEALTH ALLIANCE | OTHER |