1083932602 NPI number — ADVANCED SPORTS MEDICINE SC

Table of content: (NPI 1083932602)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083932602 NPI number — ADVANCED SPORTS MEDICINE SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED SPORTS MEDICINE SC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083932602
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1750 N RANDALL RD
Provider Second Line Business Mailing Address:
SUITE 250
Provider Business Mailing Address City Name:
ELGIN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60123-7900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
224-856-2494
Provider Business Mailing Address Fax Number:
224-856-2495

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1750 N RANDALL RD
Provider Second Line Business Practice Location Address:
SUITE 250
Provider Business Practice Location Address City Name:
ELGIN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60123-7900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
224-856-2494
Provider Business Practice Location Address Fax Number:
224-856-2495
Provider Enumeration Date:
05/06/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MITCHELL
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
630-346-3600

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  038009968 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)