Basic Information
| Provider Information | |||||||||
| NPI: | 1710261623 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY ORTHOPEDICS & SPORTS MEDICINE, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1449 | ||||||||
| Address2: | |||||||||
| City: | MARYLAND HEIGHTS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630430449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144322580 | ||||||||
| FaxNumber: | 3144320223 | ||||||||
| Practice Location | |||||||||
| Address1: | 818 E BROADWAY ST | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | SPARTA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622861820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184432177 | ||||||||
| FaxNumber: | 6184431324 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2011 | ||||||||
| LastUpdateDate: | 10/11/2011 | ||||||||
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| AuthorizedOfficialLastName: | ADDERLEY | ||||||||
| AuthorizedOfficialFirstName: | TAMMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 3144322580 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY ORTHOPEDICS & SPORTS MEDICINE, PC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 036109093 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.