Basic Information
| Provider Information | |||||||||
| NPI: | 1225473952 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOPEDIC & SPINE SURGERY ASSOC LTD | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MIDWEST BONE & JOINT INSTITUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2350 ROYAL BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ELGIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601234719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479315300 | ||||||||
| FaxNumber: | 8479315321 | ||||||||
| Practice Location | |||||||||
| Address1: | 1710 N RANDALL RD | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | ELGIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601239400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2242931170 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2013 | ||||||||
| LastUpdateDate: | 05/08/2013 | ||||||||
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| AuthorizedOfficialLastName: | WALLENIUS | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 8479315300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.