Basic Information
| Provider Information | |||||||||
| NPI: | 1205374717 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WHEATON ORTHOPAEDICS, LTD | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SPORTSMED-WHEATON ORTHOPAEDICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 327 GUNDERSEN DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | CAROL STREAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601882402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306659155 | ||||||||
| FaxNumber: | 6306659770 | ||||||||
| Practice Location | |||||||||
| Address1: | 1971 GOWDEY RD | ||||||||
| Address2: | SUITE 207 | ||||||||
| City: | NAPERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605634232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306659155 | ||||||||
| FaxNumber: | 6306659770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2017 | ||||||||
| LastUpdateDate: | 02/03/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BAKER | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 6306659155 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WHEATON ORTHOPAEDICS, LTD | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 042001705 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0002215428 | 01 | IL | BLUE CROSS BLUE SHIELD OF ILLINOIS | OTHER | 130944200 | 01 | IL | US DEPARTMENT OF LABOR | OTHER |