Basic Information
| Provider Information | |||||||||
| NPI: | 1164972311 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOPAEDIC CENTER OF ILLINOIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 S KOKE MILL RD | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627119252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175479100 | ||||||||
| FaxNumber: | 2175479236 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 S KOKE MILL RD | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627119252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175479100 | ||||||||
| FaxNumber: | 2175479236 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2016 | ||||||||
| LastUpdateDate: | 11/20/2020 | ||||||||
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| AuthorizedOfficialLastName: | ROETHEMEYER | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2175479100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070022423 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.