Basic Information
Provider Information | |||||||||
NPI: | 1033364534 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WHEATON ORTHOPAEDICS, LTD. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SPORTSMED WHEATON ORTHOPAEDICS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 327 GUNDERSEN DR | ||||||||
Address2: | SUITE A | ||||||||
City: | CAROL STREAM | ||||||||
State: | IL | ||||||||
PostalCode: | 601882402 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6306659155 | ||||||||
FaxNumber: | 6306655557 | ||||||||
Practice Location | |||||||||
Address1: | 327 GUNDERSEN DR | ||||||||
Address2: | SUITE A | ||||||||
City: | CAROL STREAM | ||||||||
State: | IL | ||||||||
PostalCode: | 601882402 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6306659155 | ||||||||
FaxNumber: | 6306655557 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/25/2008 | ||||||||
LastUpdateDate: | 11/25/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MARTIN | ||||||||
AuthorizedOfficialFirstName: | MAMIE | ||||||||
AuthorizedOfficialMiddleName: | T | ||||||||
AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 6307843295 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | WHEATON ORTHOPAEDICS, LTD | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 041261134 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse |   | 163W00000X | 041162131 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse |   |
ID Information
ID | Type | State | Issuer | Description | 02233497 | 01 | IL | BLUE CROSS BLUE SHIELD OF ILLINOIS | OTHER |