Basic Information
| Provider Information | |||||||||
| NPI: | 1619640331 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GREYLEDGE ORTHOBIOLOGIC GROUP LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1660 FEEHANVILLE DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | MOUNT PROSPECT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600566019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3124751893 | ||||||||
| FaxNumber: | 8473909345 | ||||||||
| Practice Location | |||||||||
| Address1: | 1660 FEEHANVILLE DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | MOUNT PROSPECT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600566019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3124751893 | ||||||||
| FaxNumber: | 8473909345 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2021 | ||||||||
| LastUpdateDate: | 02/15/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHEINKOP | ||||||||
| AuthorizedOfficialFirstName: | MITCHELL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3124751893 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 02/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 208VP0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.