Basic Information
| Provider Information | |||||||||
| NPI: | 1700140613 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIDAMERICA ORTHOPAEDICS, S.C. | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MIDAMERICA HAND TO SHOULDER CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 19065 HICKORY CREEK DR | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | MOKENA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604488507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082377200 | ||||||||
| FaxNumber: | 8158380590 | ||||||||
| Practice Location | |||||||||
| Address1: | 19065 HICKORY CREEK DR | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | MOKENA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604488507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082377200 | ||||||||
| FaxNumber: | 8158380590 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2012 | ||||||||
| LastUpdateDate: | 06/26/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FAKHOURI | ||||||||
| AuthorizedOfficialFirstName: | ANTON | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7082377200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2082S0105X | 036-095853 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery | Surgery of the Hand | 207X00000X | 036-084909 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.