Basic Information
Provider Information | |||||||||
NPI: | 1578628640 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ORTHOPEDIC & SPINE SURGERY ASSOC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MIDWEST BONE & JOINT INSTITUTE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2350 ROYAL BLVD | ||||||||
Address2: | SUITE 200 | ||||||||
City: | ELGIN | ||||||||
State: | IL | ||||||||
PostalCode: | 601234719 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8479315300 | ||||||||
FaxNumber: | 8479315321 | ||||||||
Practice Location | |||||||||
Address1: | 420 W NORTHWEST HWY | ||||||||
Address2: | SUITE M | ||||||||
City: | BARRINGTON | ||||||||
State: | IL | ||||||||
PostalCode: | 600106837 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8473826766 | ||||||||
FaxNumber: | 8473826782 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/27/2006 | ||||||||
LastUpdateDate: | 04/17/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROUSE | ||||||||
AuthorizedOfficialFirstName: | BARBARA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 8479315300 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 335E00000X |   |   | Y |   | Suppliers | Prosthetic/Orthotic Supplier |   |
ID Information
ID | Type | State | Issuer | Description | 208821 | 01 | IL | MEDICARE | OTHER |