Basic Information
| Provider Information | |||||||||
| NPI: | 1841330354 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOPEDIC & SPINE SURGERY ASSOC | ||||||||
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| OtherOrganizationName: | MIDWEST BONE & JOINT INSTITUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2350 ROYAL BLVD | ||||||||
| Address2: | 200 | ||||||||
| City: | ELGIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601234719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479315300 | ||||||||
| FaxNumber: | 8479315321 | ||||||||
| Practice Location | |||||||||
| Address1: | 2350 ROYAL BLVD | ||||||||
| Address2: | 200 | ||||||||
| City: | ELGIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601234719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479315300 | ||||||||
| FaxNumber: | 8479315321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2007 | ||||||||
| LastUpdateDate: | 06/16/2016 | ||||||||
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| AuthorizedOfficialLastName: | GITELIS | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8479315300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | CG2631 | 01 | IL | RR MEDICARE MCHENRY CTY | OTHER | 208821 | 01 | IL | MEDICARE | OTHER | 4515176 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER | 207906 | 01 | IL | MEDICARE | OTHER | CE6001 | 01 | RAILROAD MEDICARE | OTHER |