Basic Information
| Provider Information | |||||||||
| NPI: | 1124148739 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEDICAL ALLIANCE FOR CORRECTIVE AND RECONSTRUCTIVE ORTHOPEDIC SURGERY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MACROS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5540 W 111TH ST | ||||||||
| Address2: | |||||||||
| City: | OAK LAWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604535574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084238440 | ||||||||
| FaxNumber: | 7086582958 | ||||||||
| Practice Location | |||||||||
| Address1: | 5540 W 111TH ST | ||||||||
| Address2: | |||||||||
| City: | OAK LAWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604535574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084238440 | ||||||||
| FaxNumber: | 7086582958 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2007 | ||||||||
| LastUpdateDate: | 09/05/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCCLELLAN | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7084238440 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 036055747 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.