Basic Information
| Provider Information | |||||||||
| NPI: | 1215938170 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WHEATON ORTHOPAEDICS, LTD. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 327 GUNDERSEN DR | ||||||||
| Address2: | STE A | ||||||||
| City: | CAROL STREAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601882402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306659155 | ||||||||
| FaxNumber: | 6306655557 | ||||||||
| Practice Location | |||||||||
| Address1: | 327 GUNDERSEN DR | ||||||||
| Address2: | STE A | ||||||||
| City: | CAROL STREAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601882402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306659155 | ||||||||
| FaxNumber: | 6306655557 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2005 | ||||||||
| LastUpdateDate: | 01/28/2009 | ||||||||
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| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | MAMIE | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6306659155 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 42001705 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | CM4157 | 01 | IL | RAILROAD MEDICARE PROV NO | OTHER | 2215428 | 01 | IL | BLUESHIELD PROVIDER NO | OTHER | 6017960001 | 01 | IL | NSC | OTHER | 130944200 | 01 | IL | US DEPT LABOR | OTHER |