Basic Information
| Provider Information | |||||||||
| NPI: | 1427123926 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOPEDIC SPECIALISTS SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 360 W BUTTERFIELD ROAD | ||||||||
| Address2: | SUITE160 | ||||||||
| City: | ELMHURST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307829600 | ||||||||
| FaxNumber: | 6307821643 | ||||||||
| Practice Location | |||||||||
| Address1: | 675 W NORTH AVE | ||||||||
| Address2: | SUITE314 | ||||||||
| City: | MELROSE PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601601634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307829600 | ||||||||
| FaxNumber: | 6307821643 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2006 | ||||||||
| LastUpdateDate: | 02/10/2010 | ||||||||
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| AuthorizedOfficialLastName: | PANCAMO | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 6303334447 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 213ES0103X | 016005007 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 02222323 | 01 | IL | BCBS | OTHER |