Basic Information
| Provider Information | |||||||||
| NPI: | 1275618480 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BELLEVILLE ORTHOPEDICS, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4550 MEMORIAL DR | ||||||||
| Address2: | SUITE 460 | ||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622265359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182352900 | ||||||||
| FaxNumber: | 6182352902 | ||||||||
| Practice Location | |||||||||
| Address1: | 4550 MEMORIAL DR | ||||||||
| Address2: | SUITE 460 | ||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622265359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182352900 | ||||||||
| FaxNumber: | 6182352902 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 01/15/2009 | ||||||||
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| AuthorizedOfficialLastName: | MIRLY | ||||||||
| AuthorizedOfficialFirstName: | HARVEY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6182352900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 036085921 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.