Basic Information
| Provider Information | |||||||||
| NPI: | 1356451355 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHICAGO ORTHOPAEDIC & SPORTS MEDICINE SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3000 N HALSTED ST | ||||||||
| Address2: | 525 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606575188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7738800400 | ||||||||
| FaxNumber: | 7738800066 | ||||||||
| Practice Location | |||||||||
| Address1: | 2845 N SHERIDAN RD | ||||||||
| Address2: | SUITE 6400 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606575194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7736658400 | ||||||||
| FaxNumber: | 7736658716 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 10/13/2015 | ||||||||
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| AuthorizedOfficialLastName: | GUELICH | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7738800400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 130813301 | 01 | DEPT OF LABOR | OTHER | CC4422 | 01 | IL | RR MEDICARE | OTHER |