Basic Information
| Provider Information | |||||||||
| NPI: | 1043299795 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SPORER | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 WESTBROOK CORPORATE CTR | ||||||||
| Address2: | #240 | ||||||||
| City: | WESTCHESTER | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601545701 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 25 NORTH WINFIELD ROAD | ||||||||
| Address2: | |||||||||
| City: | WINFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306825653 | ||||||||
| FaxNumber: | 6306828946 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2006 | ||||||||
| LastUpdateDate: | 09/18/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0114X | 036106085 | IL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 207073 | 01 | IL | MEDICARE PTAN LOCALITY 15 | OTHER | 036106085 1 | 05 | IL | MEDICAID | 207067 | 01 | IL | MEDICARE PTAN LOCALITY 16 | OTHER | 7895485 | 01 | IL | AETNA ID# | OTHER | P00091910 | 01 | IL | RR MEDICARE ID# | OTHER | DA4902 | 01 | IL | RR MEDICARE PTAN # | OTHER | 1633878 | 01 | IL | BCBS GROUP ID# | OTHER |