Basic Information
| Provider Information | |||||||||
| NPI: | 1881764215 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOPEDIC SPECIALISTS, S.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 360 W BUTTERFIELD ROAD | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | ELMHURST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601262005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307829600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 360 W BUTTERFIELD ROAD | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | ELMHURST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307829600 | ||||||||
| FaxNumber: | 6307821643 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 02/10/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 10/06/2008 | ||||||||
| NPIReactivationDate: | 10/29/2008 | ||||||||
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| AuthorizedOfficialLastName: | PANCAMO | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 6303334447 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.