Basic Information
| Provider Information | |||||||||
| NPI: | 1104897644 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FOX VALLEY ORTHOPAEDIC ASSOCIATES, S.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | FOX VALLEY ORTHOPAEDIC AMBULATORY SURGICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2525 KANEVILLE RD | ||||||||
| Address2: | |||||||||
| City: | GENEVA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601342578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305841400 | ||||||||
| FaxNumber: | 6305841733 | ||||||||
| Practice Location | |||||||||
| Address1: | 2525 KANEVILLE RD | ||||||||
| Address2: | |||||||||
| City: | GENEVA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601342578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305841400 | ||||||||
| FaxNumber: | 6305841733 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2006 | ||||||||
| LastUpdateDate: | 12/26/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NAVIGATO | ||||||||
| AuthorizedOfficialFirstName: | DEBBIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 6309384011 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/26/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 7002165 | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 1530 | 01 | IL | BCBS | OTHER | 490004301 | 01 | RAILROAD MEDICARE | OTHER | CF2064 | 01 | IL | RAILROAD MEDICARE GROUP | OTHER |