1194040808 NPI number — SUBURBAN ORTHOPAEDICS

Table of content: (NPI 1194040808)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194040808 NPI number — SUBURBAN ORTHOPAEDICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUBURBAN ORTHOPAEDICS
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:
SUBURBAN ORTHOPAEDICS LTD
Provider Other Organization Name Type Code:
3
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:
1194040808
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1110 W SCHICK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BARTLETT
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60103-3007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-372-1100
Provider Business Mailing Address Fax Number:
630-372-6230

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 BIESTERFIELD RD
Provider Second Line Business Practice Location Address:
STE 565
Provider Business Practice Location Address City Name:
ELK GROVE VILLAGE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60007-3361
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-439-9488
Provider Business Practice Location Address Fax Number:
847-439-9498
Provider Enumeration Date:
04/06/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ORTIZ
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE & COMPLIANCE ADMINISTRATOR
Authorized Official Telephone Number:
630-372-1100

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  038007742 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207X00000X , with the licence number: 036064932 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XS0117X , with the licence number: 036097451 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208100000X , with the licence number: 070012618 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 085001660 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 085002852 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 036064932 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01626816 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".